Stepping In, Stepping Out, Stepping Up · Stepping In, Stepping Out, Stepping Up Research Evaluating the Ward Sister Supervisory Role (REWardSS) ... of the new role, facilitating

Stepping In, Stepping Out, Stepping Up

Research Evaluating the Ward Sister Supervisory Role (REWardSS)

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Acknowledgements

We would like to thank all the ward sisters, charge nurses, senior nurse managers and other health care staff whoparticipated in this study. Ward sisters and charge nurses were very generous in giving us their time and sharingopenly their experiences of moving into a supervisory ward sister role. Without such generosity of spirit this studywould not have been possible. We would also like to take this opportunity to thank the two study sites for allowing usaccess to their staff, and to the Project Advisory Group who engaged with the study and provided advice.

Linda Watterson, Research and Innovation Manager, Nursing Department, Royal College Nursing

Lynne Currie, Research Analyst, Nursing Department, Royal College Nursing

Professor Kate Seers, Director, RCN Research Institute, University of Warwick

RCN Legal Disclaimer

The RCN shall not be liable to any person or entity with respect to any loss or damaged caused or alleged to be caused directly or indirectly bywhat is contained in or left out of this research study or damage caused or alleged to be caused directly or indirectly by what is contained in orleft out of this information and guidance.

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN

© 2015 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmittedin any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. Thispublication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in whichit is published, without the prior consent of the Publishers.

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R O Y A L C O L L E G E O F N U R S I N G

Stepping In, Stepping Out, Stepping UpResearch Evaluating the Ward Sister Supervisory Role (REWardSS)

Contents

Executive summary 4

Chapter 1: Introduction 6

1.1 Background to the literature 6

1.2 Background to study 6

Chapter 2: Study design 8

2.1 Research methodology and methods 8

2.2 Research question 8

2.3 Objectives 8

2.4 Project advisory group 8

2.5 Sample 8

2.6 Ethical approval 9

2.7 Recruitment 9

2.8 Study sites 9

2.9 Data collection 9

2.10 Data analysis 9

2.11 Research sponsor 10

2.12 Informed consent 10

2.13 Confidentiality and security 10

Chapter 3: Findings 11

3.1 Ward sister demographic 11

3.2 Focus group demographic 11

3.3 Core and key categories identified 11

3.3.1 Core category: Being pivotal 11

3.3.2 Key categories 13

3.3.2.1 Reclaiming all the role 13

3.3.2.2 Forging a path 16

3.3.2.3 Leading the way 21

3.3.2.4 Making connections in the organisation 24

Chapter 4: Discussion 30

4.1 Core and key categories 30

4.1.1 Being pivotal 31

4.1.2 Reclaiming all the role 32

4.1.3 Forging a path 35

4.1.4 Leading the way 36

4.1.5 Connecting with the organisation 36

Chapter 5: Conclusion and implications 39

5.1 Main findings 39

5.2 Main discussion points 40

5.3 Implications for practice/research 40

References 41

List of figures

4.1 Core and key categories 30

4.2 Model of a fully functioning supervisory ward sister 33

This study evaluated the experience of changing tosupervisory status for ward sisters through anexploration of the perceptions of ward sisters, seniornurse managers and the wider clinical team in two NHStrusts in England.

Method: Face-to-face interviews with 22 ward sisterswho had moved from working within the numbers toworking as a supervisory ward sister. Interviews withfour senior nursing staff and two focus groups of otherstaff (one on each site) were also undertaken. Aconstructivist grounded theory approach was utilised inthis study.

Findings:A theoretical framework was developed fromthe data to describe the experiences of the change. Thisconsists of a core category of ‘being pivotal’ supportedby four key categories:

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S T E P P I N G I N , S T E P P I N G O U T , S T E P P I N G U P

Executive summary

Being pivotal

Reclaimingthe role

Forging apath

Leading the way

Makingconnections

in theorganisation

� Supervisory ward sisters described the pivotal natureof the new role, facilitating the ability to balance keyrole elements: managing the team, being a clinicalrole model, developing and leading the ward team,representing and negotiating the interface withsenior management/wider organisation, and beingvisible for patients and their relatives.

� This role requires skill and judgement based on adetailed knowledge of the ward, gathered andinterpreted by the supervisory ward sister.Supervisory sisters continually build and update a360° view of the ward and use it to step in and out ofactivities to provide timely guidance or act as aprofessional lead as required. This almostimperceptible activity provides the basis for thesupervisory ward sister to step up and provide aninformed and effective link between the ward areaand senior levels of the organisation.

� Supervisory ward sisters were able to take a holisticview of their role, reconsider and reclaim all theelements of the role, something they reporteddifficulty with whilst working in the numbers.

� Being clinicalwas seen by supervisory ward sistersas encompassing more than caring for a patientcaseload to include working alongside staff andsharing clinical skills and knowledge.

� Supervisory ward sisters took control of their ownuse of time, reporting an improved balance betweenclinical and managerial elements of their work.

� Supervisory ward sisters forged a path for themselvesby embracing the role, reflecting on their leadershipstyle and reinforcing the ward sister’s role as ‘seniorcolleague’ rather than just another pair of hands.

� Many reported an increased feeling of autonomy andfeeling less stressed.

� Perceptions of others about the role are shifting withsome band 5 and 6 nurses now interested in theprospect of a supervisory ward sister role themselvesas the supervisory ward sister had given them avision of their future.

� Supervisory ward sisters felt able to take a moreeffective leadership role, developing staff by beingalongside them and managing their team effectively.

� By providing a professional role model and settingclear expectations, they empower staff through thissupportive/developmental approach and act as a keypoint of professional socialisation within their area.

� Making connecting in the organisation is animportant dimension of their role and manysupervisory ward sisters gave examples ofunderstanding of the complex elements aroundfrontline performance and making well informed,insightful connections between the ward and thewider organisation.

� Organisational support is needed so supervisoryward sisters can flourish and deliver all elements ofthe role effectively.

� Support includes investment to initiate and sustainthe role, and also provision of opportunities topromote peer group support.

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� Supervisory ward sisters are more visible asindividuals on their own ward and increasinglyvisible as a group in the organisation.

� Barriers to successful transition or functioning as asupervisory ward sister were identified. Theseinclude, staffing shortages, and lack of administrativesupport. Some ward sisters took longer than others torethink their role, particularly in terms of changinghow they deploy themselves clinically.

Main discussion points

� Overall, the supervisory role appears to be a positivemove for ward sisters including: improved work/lifebalance; increased satisfaction around developmentof others and driving up professional standards.

� The role is having a positive effect in some cases onperceptions of others particularly on ward sister roleas a potential career option.

� Supervisory ward sisters seem to be increasinglyengaging in a very informed way with qualitymeasurement and with quality improvement cycleswithin their own area.

� As their profile rises within the trusts, thesupervisory ward sisters are increasingly beingperceived as a knowledgeable asset.

� All benefits of the role are unlikely to be easilymeasureable and may not be clearly evidentimmediately after introduction of such posts. Thisshould be taken into account when evaluating theseroles.

� Support in terms of staffing backfill, removing wardsisters from the numbers and facilitating peer groupmeetings provide a supportive context forsupervisory ward sisters to embrace the full potentialof the supervisory role.

� Provision of administrative support seemedinconsistent and lack of this resource is a barrier toeffective working.

Implications for practice/research

� Organisations should ensure enabling factors such asappropriate administrative support are available tosupport the introduction of supervisory roles.

� Aspects of leadership development within the rolethat enable individuals to achieve and sustain therole over time need more exploration

� Creative ways of examining the impact ofsupervisory ward sisters are needed. There is a needto build on key performance indicators and take intoaccount less visible ways of working such as sensing,synthesising information and support anddevelopment of others. These less visible aspects ofthe role need to be recognized and valued.

� The invisible nature of large aspects of the role suchas information gathering, synthesising, organisingand sensing what is happening on the ward maycontinue to go unrecognised as a nursing quality.

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Introduction

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1.1. Background to the literature

The ward sister has been regarded as the key nursenegotiating patient care for over thirty years (Pembrey,1980) and as the person who determined what couldand could not be done by nursing staff on the ward(Lewis, 1990). Ball (1998) suggested the ward sisterwas central to the delivery of good quality patient careand identified a number of key components of theward sister role. The first is clinical nursing expert; thesecond is manager and leader of the ward team andward environment; and the third is educator of others(nurses, other healthcare professionals, patients andcarers). Lewis (1990) identified three strategiesemployed by ward sisters in undertaking their roleeffectively; defining/creating work; managing andorganising work; and doing the work.

In response to recent policy changes in health care, themanagement component of the ward sister appears tohave received greater emphasis. This includesrecruitment, staff sickness absence management,disciplinary procedures, meeting targets, budgetaryand resource control; and in many cases ward sistershave become known as ward managers. Such changeshave been regarded as heralding a loss of professionalrole and control, with some arguing that themanagement role should be removed in order to raisestandards of care (Ball, 1998).

Tensions between being a clinical expert, a leader anda manager have been cited as potentially leading torole conflict and job related stress. In addition, despitelarge workloads and increased management andleadership responsibilities ward sisters often lackautonomy, authority and the power to be effectivemanagers (Menzies-Lyth 1988). Furthermore, it hasbeen suggested that ward sisters learn their rolesthrough the apprentice/mentorship model, throughexperience and observation of others (Lewis, 1990);and that their preparation for their role is oftenhaphazard and unplanned (Ball, 1998).

Following the poor standards of care identified in MidStaffordshire NHS Foundation Trust, the FrancisInquiry Report (Francis, 2013) included arecommendation that ward sisters and nurse managersshould operate in a supervisory capacity and should

not be office bound. The ward manager should knowabout the care plans relating to every patient on theirward and should be visible and accessible to patientsand staff alike. In addition, ward managers shouldwork alongside staff as a role model and mentor,developing clinical competences and leadership skillswithin the team and ensuring that the caring cultureexpected of professional staff is being consistentlymaintained and upheld. This potentially addressessome of the concerns identified around failures inward leadership and the need to strengthen the role ofthe ward sister (Darzi, 2008; RCN, 2009; PrimeMinisters Commission (PMC, 2010).

The PMC recognised how some patients derived asense of authority, safety and confidence from wardsisters/leaders and recommended strengthening theward sister role by clearly defining their levels ofauthority and lines of accountability. These ideas havealso been endorsed by directors of nursing whoincreasingly recognise the importance of ensuring theward sister role is supported and valued to becomemore effective (Sawbridge & Hewison, 2011). Both theRCN (2009) and the PMC (2010) argue the ward sisterrole should be the lynchpin of patient experience andthat the role, once key to nursing, is now confused andshould be reclaimed. The RCN (2009) recommendedthat the ward sister role should be made supervisoryand subsequently proposed a framework for thesupervisory role (RCN, 2011). There is an increasinginterest in moving towards supervisory status for wardsisters with some NHS trusts taking action to makethis a reality. A survey of all NHS Trusts in England bySeers et al (2015) explored how supervisory wardsister roles were working. A key driver for thesupervisory role was providing time to lead. Beingpresent, being available, being visible to others, beingknowlegable and skilful, being able to develop othersand developing and maintaining standards of carewere key aspects of the role. The supervisory roleenabled supervisory ward sisters time to think andprovided clear lines of accountability. However, thesupervisory role had been implemented to varyingdegrees depending on financial and high vacancyconstraints.

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1.2 Background to the study

The study was undertaken with two NHS trusts thatgained funding to support the change to supervisoryward sister. Whilst both trusts have local arrangementsto assess the impact of the change, this study enabled abroader and deeper understanding of the ward sisters’experiences and perceptions of the change, and anunderstanding of the impact of the change on othersincluding senior nurse managers and ward teams.

In both study sites the change to supervisory statusmeant ward sisters would not be required to manage anallocated patient caseload, they would generally workcore hours during the week (Monday – Friday), but befree to deploy their time as they chose and they wouldremain accountable for a range of key performancemeasures.

Managing the change to supervisory status required anincrease in nurse staffing to enable the ward sister torelinquish their patient caseload. This uplift in staffingwas part of the planning at both study sites from theoutset, but due to the complexities attached torecruitment, employment, training, upskilling orimproving staff skills, and retaining staff, this proved tobe a major challenge following the implementation tosupervisory status. During the transition, and given thetime it took to get the staffing uplift in place, which wasvariable across both study sites, some ward sistersreported having to continue working ‘in the numbers’,which in turn impacted on their ability to fullydischarge a supervisory role

This report provides an insight into the experiences ofindividual ward sisters making the transition tosupervisory status over the period of data collection.

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Study design

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2.1 Research methodology and methods

This study collected data through the use of face-to-faceinterviews with individual supervisory ward sisters andsenior nursing managers around the time of the changeto supervisory status and 4 – 6 months later. Focusgroup interviews were used to collect data on theperspectives of the supervisory ward sister role held bymembers of the wider clinical team.

A constructivist grounded theory approach (Charmaz,2014) was used. Grounded theory is a systematicmethodology which seeks to construct theory that isgrounded in the data. Each line of data is coded, andcodes are constantly compared across all data, andgrouped into concepts. Similar concepts are reviewedand revised which leads to the identification of anumber of key categories which can then be placedunder a core category. Constructive grounded theory iscomparative, iterative and interactive and the emphasisis on the analysis of data. Early data analysis informsfurther data collection and constructivist groundedtheory has the potential to construct theory (Charmaz,2014).

Full details of the research methodology and methodswill be reported in a paper to complement this report.

2.2 Research question

The research question was:

“What impact does the change to supervisory wardsister status have on the expectations, experiences andperceptions of ward sisters, senior nurse managers andthe wider ward team?”

2.3 Objectives

The key objectives were to:

1. Explore the perspectives of those moving into asupervisory ward sister role, their interpretation andevaluation of the role, and their views on theexpectations being placed on the role.

2. Explore how senior managers and wider clinicalteams view the supervisory role

3. Construct a grounded theory of the supervisory wardsister role.

2.4 Project advisory group

A project advisory group was established whosemembership included the research team, medical,nursing and patient representation drawn from the twotrusts, educational representatives from both trusts, thelocal Royal College of Nursing (RCN) regional directorand an independent research adviser. The group mettwice during the project. The remaining interaction withthe project advisory group was undertaken using emailcommunication.

2.5 Sample

All ward sisters with a supervisory role in the two studysites were eligible for inclusion and were invited toparticipate (total=87). In total 22 ward sisters agreed toparticipate and the first interviews took place duringMar-Jun 2014 (11 ward sisters from each study site).The second interviews took place during Aug-Oct 2014with a total of 17 interviews being undertaken. Five ofthe initial group of ward sisters did not take part in asecond interview. Of these, four were happy to beinterviewed a second time, but difficulties wereexperienced in relation to finding a suitable date andtime due to annual leave and sickness prior to the end ofthe interview phase of the project. One ward sister didnot respond to the request for a second interview.Overall 39 interviews were conducted with ward sisters.In addition interviews were undertaken with four seniornurses, two from each of the study site during Jun-Oct2014. The two focus group interviews with the widerward teams, one at each study site, were carried out inNovember 2014. These were aimed at the wider clinicalteam (registered nurses, health care assistants, medicalpersonal, allied professionals) and any non-clinicalward staff who might wish to share their views aboutthe supervisory ward sister (e.g. ward clerk,administrator, housekeeper, cleaner, porter). The focus

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groups consisted of 14 staff at one site and six at theother (22 in total). Overall, 43 face-to-face interviewswere carried out and two focus groups undertaken.

2.6 Ethics approval

The study received ethical approval from the Biomedicaland Scientific Research Ethics Committee (BSREC) atthe University of Warwick in October 2013. (Ward SisterSupervisory Study BSREC REGO-2013-558 v2 14/10/13)

Both trusts also gave approval for this study to go ahead.

2.7 Recruitment

2.7.1 Ward sisters

Letters inviting participation in the study were sent toall ward sisters across both study sites. A participantinformation leaflet outlined the informed consentprocess for those wishing to be involved in the studyincluding confidentiality, data security, and right ofwithdrawal, benefits and any perceived risks.

The resulting sample comprised ward sisters with lessthan two years in post and those with experience of upto 20 years and included both female and maleparticipants.

2.7.2 Focus groups

The two focus group interviews took place in November2014 (n=22). Participants were identified to participatefollowing broad advertisement at both study sites, andrecruitment was assisted by the educationrepresentatives from each of the study sites.

2.8 Study sites

The two study sites participating in the study were twoNHS trusts.

2.9 Data collection

All Interviews were recorded with the consent of theparticipants and were transcribed in full.

2.9.1 First and second interviews with ward sisters

Data was collected through the use of qualitative, face-to-face interviews The interviews used open-ended

questions, and utilised a topic guide covering the threekey components of the ward sister role (clinical expert,leader and manager). The first round of interviews(n=22) took place as close as possible to the start of theimplementation phase and were used to capture whatthe supervisory ward sisters hoped to achieve in movinginto a new role; their vision of the role and their planson whether and how they would evaluate the role. Thesecond interviews (n=17) took place four to six monthsafter the first interview and were used to captureindividual ward sister’s perceptions on whether theirexpectations of the change to supervisory status hadbeen met, whether they had come across any enablers orbarriers. In addition, the second interviews were used tocapture further additional data on the provisionalcategories emerging from the early data analysis. Allinterviews were recorded and transcribed in full.

2.9.2 Interviews with senior nurse managersData was also collected from senior nurses at each studysite about their perceptions of the change to supervisoryward sister status. These interviews took place oncompletion of the majority of the first interviews withward sisters.

2.9.3 Focus group interviewsAdditional data was collected through the use of a focusgroup interview at each study site with members of thewider clinical teams who may have been affected by thechange to supervisory ward sister.

2.10 Data analysis

All interviews and focus groups were recorded with theconsent of the participants and were transcribed in full.All transcriptions were reviewed separately by LW & LC.Transcripts were coded line-by-line to identify actionsand processes. A process of concurrent data generationand analysis was undertaken (Charmaz, 2014). Data wascoded and emergent and key categories were identified.The researchers shared their individual analyses witheach other as they were completed, and any differenceswere resolved through discussion. This processcontinued throughout all stages of data collection andthe research team met four times to discuss theemergent findings and agree emerging codes andcategories. Analysis of the first round of interview datawas used to inform the second round of interviews.Data from the second round of interviews was subjectedto similar coding and categorisation as was the datacollected through the focus groups and the interviews

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with senior nurse managers. Full details of the researchmethodology and methods will be reported in a laterpaper to complement this report.

2.11 Research sponsor

The research sponsor for the study was confirmed as theUniversity of Warwick in a letter dated 31 January 2014,in accordance with the Department of Health’s ResearchGovernance Framework for Health and Social Care(2005).

2.12 Informed consent

All participants expressing a wish to be involved in thestudy were asked to read the participant informationsheet and complete the informed consent form.

2.13 Confidentiality and security

The identity of all participants in the study remainsconfidential. Only the core research team have access topersonal participant information held securely on RCNpremises. At the completion of the study all personalinformation pertaining to participants will bedestroyed. All participants have been given a numberand this number is used when reporting directquotations. All data, consent forms and administrativerecords are stored in a secure location. Only LW and LChave access to this information which will be held onpassword-secured computers. KS has access toanonymised transcripts. Hard copies of consent formswill be filed in locked cabinets at RCN premises; thesewill be kept securely and destroyed after 10 years.Because of the possibility that the four senior nursesmight be identifiable from their direct quotations thisdata has not been specifically labelled to maintainconfidentiality.

Participants were free to withdraw from the study at anytime without any need to provide a reason and withoutany sanctions. None of the participants expressed awish to withdraw.

3.1 Ward sister demographic

In one of the study sites the change to a supervisory rolewas rolled out across all ward sisters, whilst in the otherstudy site it was only rolled out across acute in-patientservices

The target number of participants was 15 wardsisters/ward managers from each study site (n=30), thefinal number of participants totalled 22 spread equallyacross the two sites. The sample included those with 0–5years’ experience up to those with 16-20 years. Agesranged from within categories ‘26-35’ up to ‘46–55’ andyears as a qualified nurse ranged from ‘6-10’ to ‘20+’.Number of years working as a ward sister ranged fromless than one year to 16-20 years. The sample includedboth female and male ward sisters/charge nurses. Toensure the confidentiality of all participants allinterviews with ward sisters and charge nurses aresimply identified as ‘ward sister interview’.

3.2 Focus group demographic

Twenty two participants took part in the two focusgroups, these included nursing staff, professionals alliedto medicine, ward administration, human resources andsenior nurse management. Fourteen staff attended at onesite and six at the other.

3.3 Core and key categoriesidentified

This section describes the overarching picture of theresearch participants’ perceptions, expectations andexperiences of the supervisory ward sister role asidentified in this study. The constructed groundedtheory framework emerging from the analysis identifiesthe core category as “Being Pivotal” and four keycategories that underpin this core category. The four keycategories are: reclaiming all the role; forging a path;leading the way; and connecting with the organisation(see Figure 4.1, page 30). Within each key category are anumber of sub-categories that are further described inthe following sections.

3.3.1 Core category: Being pivotal

“I’m in that prime position where I know what’s goingon, I know my staff, I know my patients, I know myteam, and I know what’s going on in the trust, so like itis a very important role. It is a very important role, youknow what I mean, being a leader and being able toimprove practice, improve patient care, improve staffand their morale and their work and wellbeing.” (Wardsister interview: 713.0020, lines 863-868)

The above quotation captures the facets of the rolewhich were described by many of the participants. Theward sister is visible as: managing the team, being aclinical role model, a source of development, interactingwith patients and leading the ward team, whilst at thesame time acting as the key interface, or bridge withsenior management and the wider organisation andhence has the overarching experience of ‘being pivotal’.What emerged from the description of their activities asgiven by the ward sisters was the way in which theyneed to skilfully negotiate this pivotal role in order todeliver on the clinical, managerial and leadershipelements and the way in which this was facilitated bysupervisory status.

The next section further illustrates this core category of‘being pivotal’, before going on to present data from thefour key categories.

A sense emerged that the supervisory ward sistersteered things, making adjustments as they went along.

“I suppose I’m the rudder.” (Ward sister interview713.0018a/b, line: 779)

There was also a sense of monitoring in order to maketimely adjustment.

“For me it’s about focusing what is going on, on theward and what the prioritise of the day are, um, andhelping the nurses on the ward to understand what theyneed to do first so how to prioritise really. But I’ve got afinger on the pulse so I know that I can push thingsforward.” (Ward sister interview 713.0015, lines: 61-66)

The notion of balancing or juggling featured commonly,particularly in relation to the clinical and managerialaspects of the role.

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3

Findings

“It is hard to do both of them because you have to weartwo different hats in a sense, don’t you? I mean themanagement aspect of it is... the management aspectsyes it’s fine. I think I’m... I think I’m managing it okay[laughs]; I think yes, I manage it okay. I’m firm withthem, they know... yes I’m just trying to think... yes, Iachieve it fine at... well not at the moment, my office is abit of a mess, but yes I achieve it okay, and I’m able toget that balance in to do it.” (Ward sister interview713.0022, lines: 336-344)

“Balancing it out a bit more I’m hopeful that I will getthat time to release to work clinically and, um, justgetting on top of things, keeping on top of the work loadand maintaining the, um, sort of like the targets reallythat I’m at my set trajectory and balancing that withactually me getting out there and influencing care on award level basis.” (Ward sister interview 714.0004, lines:857-862)

“I mean when it’s working well it works well and you’reable to in a sense multi-task and do everything thesupervisory status allows you to do.” (Ward sisterinterview 713.0022, lines: 230-232)

In describing having to balance their workload therewas also a clear sense that ward sisters had struggledpreviously to deliver or successfully balance all theaspects of their role alongside having a patient caseload.

“I don’t know whether it was because I was tired orwhether I was just so involved I couldn’t stand back andbe objective but um, I’ve found myself with more of avision ...of certain things across the board which I feltwas starting to wane a little bit previously.” (Ward sisterinterview 713.0004, lines: 135-138)

Building up good, first-hand information andimpressions of how the ward was working in order tobalance and adjust activities was described bysupervisory ward sisters as something that they hadbeen more able to do, since the change.

“Talking to the patients, go round making sure they’reall OK... I do a quick audit looking at the notes makingsure they’re alright. Making sure all the infection controlstuff has all been done – so like the cleaning’s beendone. Because you kind of do this as you’re going roundpicking up the folders checking everything’s been doneseeing that it looks and feels OK...” (Ward sisterinterview 713.0012a/b, lines: 1174-1179)

“I think it is what you make of it yourself and the moretime you invest in your clinical environment. I meansometimes, um, from an outsiders point of view it maylook like I’m not doing anything at all but often... when

there’s a natural lull... sometimes it’s nice just to ... justhave a chat and you do get a feel, sort of take thetemperature of your ward, you know, of what sort ofmood your staff are in at the end of a nearly 12 hourshift, are they still upbeat, do they look a bitdowntrodden, what, you know... just a few words and it’samazing how you’ll pick up that someone’s notthemselves, you know, and then you can pick a bitdeeper and find out.” (Ward sister interview 713.0011,lines: 134-156)

Acquiring this understanding seemed to be acontinuous process, and yet it appears to be done almostimperceptibly. Ward sisters talked about how doing awalkaround, whilst simultaneously observing patientand staff interactions meant they were being able toobserve whether or not the patients appeared cared forand happy.

“Yesterday was good because... I enjoyed the fact that... Igot to do the drugs round. So I was off to do the drugsround and I could talk to all the (patients) as I wentround and... you have a little banter with the patientsand then you come back and you go and help with someturns and there wasn’t many emails when I checkedwhich was lovely. So you are thinking ‘Oh right I haven’tgot to do very much with that...’ ...so I could be out thereand when the visitors came I was able to go round thebays and have a chat to the (visitors) and speak to themand so that was a good day yesterday and I went homeand I thought ‘I thoroughly enjoyed myself today. I’vedone the drugs I’ve been actually on the ward and thatwas nice.’” (Ward sister interview 714.0017, lines: 705-720 [abridged])

This monitoring could continue even while working inthe office since many ward sisters talked about leavingthe door open. Leaving the door open not only let staffknow they could come and talk to the ward sister asthey needed, but it also allowed the ward sister toremain aware of what was going on outside.

“Sometimes I’m just sat here and think – Oh it’s all gonea bit loud out there I’d better go out and go’ OK who havewe escalated to, who have we contacted, what’shappened?’ Because I’m in here doing stuff and I justthink – I mean it’s like they did want to move my officeout of the department and I went – ‘No I need to be inthe heart of the department so I know what’shappening.’” (Ward sister interview 713.0017, lines:1056-1062)

So in addition to gathering specific informationthroughout their day ward sisters also describedbuilding up impressions, sensing or feeling what isgoing on.

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“I think as a nurse you have ears everywhere don’tyou... and I think that’s probably something that youlearn as time goes on so if I hear something said that Ithink what’s going on I will go and delve so that I can tryand resolve things before they get out of hand.” (Wardsister interview: 713.0015, lines: 191-196)

“...and the girls were starting to struggle and I could feelthe tension out there. So my priority is to alleviate thattension.” (Ward sister interview 714.0014, lines: 87-89)

Many ward sisters described gaining an ‘overview’ oftheir ward. They were then able to use this knowledgeand understanding to judge when they needed to step into nip any potential issues in the bud.

“ It’s not just being above looking down but you canactually step in... you can actually step in and workalongside someone that you think is actually struggling,or if there’s a potential issue with some relatives that youforesee, you can actually go and speak to them before itgets out of hand.” (Ward sister interview 713.0030, lines:65-75)

Ward sisters also reported how this overview was moreeffectively gained if you were freed from being focusedon managing your own patient caseload.

“...you’ve got an overview haven’t you and you can sortof like stand back and actually watch this behaviour in adifferent way. So you’re not... if you’re in it you can’t seeit so much, but if you’re on the periphery you canactually see what’s going on. So it does give youempowerment for that really.” (Participant, Focus GroupB, lines: 1091-1095)

This freedom also enabled ward sisters to deploythemselves in the most strategically useful way.

“...being supervisory allows me to do my ward roundswith my consultants... I don’t get pulled into other tasks.I can stick it out for the duration, I pride myself by thefact that I know every single patient on my ward and Ican sit here, I don’t need a handover and I can tell youwhat is wrong with every single patient and what I’mwaiting for in regards to their discharge. If I wasinvolved in their care and probably having toconcentrate on a team, with 28 patients, divided intotwo teams, I think I would probably know that for halfof the ward but would I know the whole ward, I don’tknow.” (Ward sister interview 714.0006, lines: 45-56)

Working in this way also meant that they were felt to bemore visible to other staff and to patients, and this wasclearly appreciated.

“If the supervisory ward sister was present and outclinically on the ward and visible they can actually

resolve it at the point of the problem happening. And(relatives) ... were very, very impressed with that, thepresence of the senior sister being out on the ward,being on ward rounds, being visible across the whole ofthe unit, you know, covering all of the areas that wecover. Um, they were actually very, very impressed withit and that was even fed back regularly on a daily basisthat (relatives, patients) and visitors to the unit youknow, it was good to see us out there and on the unit”.(Participant, Focus Group B, lines: 20-28)

3.3.2 Key categories The overarching category described in the previoussection ‘being pivotal’ is underpinned by four keycategories, and these are described in the followingsections.

The first of these key categories is reclaiming all therole, which includes redefining being clinical; deployingself differently; stepping in/stepping out and autonomy,influence and being in control.

3.3.2.1 Key category 1: Reclaiming all the role It appears from the data that the move to supervisorystatus prompted ward sisters to reflect on elements oftheir role. Many of the ward sisters reported embracingand fulfilling these elements more effectively throughthe opportunities afforded them by the change. Asdescribed above a number had reported feelingelements of their role had previously been constrained.Therefore it seems that as part of the experience of thetransition to supervisory status, the ward sistersreconsidered and redefined aspects of their role,ultimately ‘reclaiming’ it in its totality.

Re-defining being clinical

“So that’s three hours today that I’ve been out theresupporting the department, doing the post-take wardround, finding out about the poorly patients andknowing what’s going on and I’ve really, reallythoroughly enjoyed it and thought this is what I reallywant to do, um, and yesterday I spent two hours outthere cause we had (two urgent patients) ...So I took theother one, um, and I thought ‘Ohhhh this is aboutnursing, yes I like this.’” (Ward sister interview713.0016, lines: 638-64)

The transition to supervisory status led to a number ofward sisters to reflect on what ‘being clinical’ means inthe context of the supervisory role. A passion fornursing was clearly discernible in the way ward sisterstalked about their work. The clinical element of nursing,

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in the sense of direct caring interaction with patientswas cited by many ward sisters as their motivation forbecoming a nurse, and delivering patient-centred careas the reason they continued to nurse. Some ward sistersdescribed a sense of satisfaction in providing one to onecare and a few noted that having a caseload meant theycould engage with those specific patients in a morerewarding way. Some ward sisters reported experiencinganxiety because they saw supervisory as not beingclinical, and suggested that having a patient caseloadand being clinical in this way was what nursing wasabout. However, many acknowledged that when theyhad a patient caseload there was always the possibilityof being pulled away for managerial issues.

“I feel I’m de-skilling as a nurse. From a practical pointof view...” (Ward sister interview 714.0004, lines: 34-35)

“I do miss having my patients, yes, um, but it’s nicewhen you can get out there... it’s difficult with a caseload because if you have your own patients you’re stillgoing to be pulled away by other people, because they’regoing to come and they’re not going to just leave you –I’m clinical today I’m looking after my own patients –‘No but we need you to do this’, or ‘Can you come and dothat?’ and that draws you away from your patients. So Idon’t ever think that perhaps definitely as a 7... you’renot going to be pulled away from your patient carebecause you will be.” (Ward sister interview 714.0017,lines: 1173-1182)

With the move to supervisory status, many ward sistersspoke about seeing their clinical role as one that enabledthem to deploy themselves differently to undertakespecific clinical activities. Many supervisory wardsisters spoke about being able to make personal contactwith patients regularly. They also talked about allocatingthemselves to work alongside staff. This approachenabled the ward sisters to retain their skills whilst atthe same time facilitating staff development.

“If patients need me I’m there. Every day I go round andI talk to my patients. If I was clinical there was no way Icould do that. But I do go round and that’s reflected inthe feedback that we get that, you know, I go round andmake beds, I talk to patients, I ask them how they are,but being clinical I couldn’t do that, not at all.” (Wardsister interview 713.0020, lines: 135- 140)

“...so I envisage it as either me being extra to thenumbers to be supportive of the junior staff on the floor,I mean I might have a band 5 that co-ordinates on thatday so I’m there to providing support and guidance forher on that day so that she’s developing hermanagement skills, or we’ve had quite new starters so

it’s working with directly with those in the bays. Makingsure that they know what standards...” (Ward sisterinterview 714.0005, lines: 31-36)

“..and if a staff nurse needed support then I would goand help them, you know, if they wanted to do adressing or look at a pressure ulcer or look at a woundor, you know. Just to be there for them to say (sister) canyou help me look at this or, you know, I think it’s to bevisible and to be there for them if they need, just thatsenior person.” (Ward sister interview 713.0008, lines:767-773)

Deploying self differently

Supervisory ward sisters described deployingthemselves differently, with some appearing to need torebalance the amount of time they spent on the differentelements of the role. This was particularly evident wherechoices were being made about working on managerialactivities in the office, or undertaking clinically basedactivities. Priorities had been governed previously bythe patient caseload taking precedence, which wardsisters reported as having to put managerial issues onhold and catch up on them later, working extra hours ortaking work home. The experiences in this regard werevarious:

“I can use my time more efficiently I can ensure that weare meeting the standards. So it’s not a race against theclock every day to just do a little bit here and there I canactually check that we are doing the things that weshould be doing. That I can actually observe we’re doingthe things that we should be doing. I’ve got a feel forwhat’s going on – well I actually know what’s going on.”(Ward sister interview 713.0012a/b, lines: 1260-1267)

“um, and I think it took me a good three or four monthsto kind of get my head round the routine of what I wasdoing and how I was doing it. There was a lot of othermeetings that you go to, which takes up a lot of time,and obviously you have your, um, on call rota, so I dothat once a week so that’s another day out as well. Sothere is a lot going on but I don’t seem to be out on theward where I want to be really.” (Ward sister interview714.0004, lines: 21-29)

However a pattern of the general approach todeployment across the day by supervisory ward sisterswas discernible.

“I feel more organised now erm so I manage my time byhaving my clinical time in the morning and then in theafternoon I’m freed up to do anything I’ve got to do inhere you know. Any meetings I’ve gotta go to, so I feel alot better about that. And I think it seems to fit better on

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the ward. The staff know that I’ll be on the ward tillabout half eleven twelve and then they respect that I’vegotta come in and be on top of you know, my...paperwork really, so yeah.” (Ward sister interview713.0010, lines: 36-42)

Stepping in/stepping out

In the supervisory role, this flexible deployment meantthat ward sisters could step in and step out of situations.Decisions on how and when to step in and out were inresponse to the overall picture being built up by thesupervisory ward sister as previously described.

“...like I say, spend more time with staff, I’ll still workclinically so. Like I say it’s more of a supervisory role soI’m, um, able to step in help and then come away again.”(Ward sister interview 713.0012a/b, lines: 58-61)

Being flexible in the way they undertook their variousactivities meant that the supervisory ward sisters wereable to step out and observe the clinical environmentand then step in to make adjustments.

“The best thing is that I am able to stand on the outsidelooking in more ...I can have a real strong overview andI can put something right much quicker. If I’m nothappy with standards then I’m able to act much quicker,and do something quicker. ...it can’t always make thesituation easier to deal with because it is what it is. But itcertainly makes you have that sort of 360° view ofsomething rather than just going in there, blinkeredvision because you’re just too busy doing other things. Itgives you an overview of everything that’s going on andyou can act quicker if something is not going right andyou are more visual out there as well up and down theward with relatives who may have a potential complaint,so you’re de-escalating because you’re there as a seniorperson sorting things out.” (Ward sister interview714.0014, lines: 789-813)

“but the joy of it is when you are truly supervisory thatyou can dip in and out cause you can’t do that whenyou’re in the numbers cause as soon as you get pulledaway to do something else, you’re leaving them shortand it gets to the point where they don’t like youworking in the numbers because they can’t trust you tobe there. Um, and that’s not a healthy relationship tohave with your staff. I like them to know I’m around onthe ward and to be glad to see me.” (Ward sisterinterview 713.0011, lines: 38-46)

Autonomy, influence and being in control

Many ward sisters talked of embracing the sense offreedom they felt they now had through being able to be

flexible to use their time as they saw fit. Many also feltthe move to supervisory status had resulted in anincreased sense of authority and influence, and hadallowed them to take greater control of their ward inorder to fulfil their accountability and responsibility forthe standard of care provided.

“Things have definitely settled down... I just still feel likeI’m just still gaining a bit more control. I think last timewe spoke I think I felt that I was getting in control of it...”(Ward sister interview 714.0031, lines: 15-17)

“I wasn’t thinking outside the box, I wasn’t being myself,and I was being what (someone else) thought I shouldbe, you know. And yes we were getting results, we weregetting what we wanted, but the staff weren’t happy. AndI could see that, so I decided that, you know... I went tosome coaching myself and they made me realise that itwas okay to be who I was and how I am. This coincidedwith me becoming a supervisory ward sister and I justdecided that, no I’m going to be honest and open andsay, this is what I think will work, let me try it and if itdoesn’t we’ll do it your way, but, let me... and now I’mvery confident and I go, no this is what I’m doing andthis is why I’m doing it.” (Ward sister interview713.0020, lines: 645-655)

Where ward sisters felt they had autonomy andinfluence they did raise issues and challenge negative orunrealistic expectations. However, others were lessconvinced, feeling that power was given to them withone hand, and then taken away with the other.

“...it’s only recently that we can put bank shifts out forour own ward... You know what I mean and we were likewell, you know, you put us on a bleep rota and you trustus to take charge of this hospital out of hours and yetwe’re not allowed to put a bank shift out... You know wecan’t request an agency nurse – we’re are not going to gomad, trust me, you know, we are not going to go madwith your budget – it’s just, err, I think that we haveextremes.” (Ward sister interview 713.0008, lines: 1626-1641)

The issue of autonomy was particularly evident whenward sisters described the expectations matrons hadabout the supervisory ward sister role. While someclearly identified having a collegial relationship withtheir matron, others described being micro managed.While the former group talked about feeling supportedand appreciative in terms of being left to manage theirward as they saw fit, the latter group reported feelingconfused, angry or just fed up. On the one hand theywere being told they had authority and accountability tomanage their ward, whilst on the other hand they

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reported finding themselves having to seek the matron’spermission before they could make a decision.

“I get by-passed time and time again through matronand you’ll be amazed how many people don’t evenbother, they’ll just copy me in, or I’ll get stuff forwardedto me by the matron... They will communicate to thematron and completely cut me out of the loop. And thathappens a lot. So they, they tell us that, you know, theywant to bring back the power and the authority but thereality of it is... that power and authority has beeneroded away and we’re not going to get it back any timesoon. They say we’re a powerful group, well, not reallybecause we’ve got a whole set of matrons and, you know,we have to do as we’re told, like they do...” (Ward sisterinterview 713.0011, lines: 1076-109)

3.3.2.2 Key Category 2: Forging a pathThis category emerged from the analysis that revealedthat in addition to reviewing elements of the ward sisterrole, the transition to supervisory status had alsoprompted some ward sisters to engage in self-reflectionand self-awareness particularly in relation to their roleas a leader. Many had drawn comparisons between howthey had worked in the past and how they might workor had begun to work in the new role.

Participants described a range of emotions and feelingsand explored their vision for themselves and their staff,including how they could fulfil their own and theirstaff ’s full potential, how they might expand into thesupervisory role in order to drive up standards, and theneed for self-belief that they could be a supervisoryward sister. This appeared easier for some than forothers, and it seems to be influenced by where each ofthem was in terms of their personal development as award sister at the beginning of the change tosupervisory status. The sub-categories underpinningthis key category are identified as enthusiasm for therole; not being one of the gang; driving improvements inpatient care; reversing negative perceptions of the wardsister role; knowing self; flying in the role; anddifficulties moving into the role.

Enthusiasm for the role

Overall ward sisters reported enthusiasm for thesupervisory role and the changes it had facilitated.Many initially greeted the introduction of supervisorystatus with both anxiety and excitement; with somereporting clear ideas about what they hoped to achievein the role.

“I think it’s the right thing for us as band 7s because it’s

what we need to do. We need to be out there in the ward,um, pushing things forward whatever it might be... weneed to be out there and we need to be visible so thatthey can that those on the ward can see that we’releaders. Um, and we can also, we can nurture, we canteach, we can share our experience, um, without havingclinical, without having to try and look after patientsclinically as well, um, it is, it was, really difficult to have acohort of patients and, um, try and run the ward.” (Wardsister interview: 713.0005, lines: 9-20)

“It’s my job to know everything’s that’s going on, to pickit up, to challenge poor practice, um, to, um, to supportmy staff, um, to sit with my patients when they’re upset,um, absolutely, I need to know. And I don’t think I wouldhave the same job satisfaction, um, and I think I wouldbe far more stressed. Because I think I would worryabout what I didn’t know, whereas now... I go homefeeling confident that I do know what’s going on.” (Wardsister interview 714.0006, lines: 1347-1352)

Driving improvements in patient care

Ward sisters described their intention to make the rolework because they believed in its potential to hugelybenefit improvements in patient care. Many saw thesupervisory ward sister role as embodying what theward sister should be doing as opposed to what mostperceived as the fire fighting approach required in therole they had experienced before the change.

“I think it’s just... I suppose it’s the flexibility to be ableto improve anything you know, whether that is patientcare, your patient journey, your patient experience, yournursing skills. Just having that flexibility to make theimprovements and to start to look at the bigger pictureand not kind of feel that you’re in there fire-fighting, it’sbeing able to say okay, that’s okay and now we need tolook at this because this isn’t quite right. So it’s abouthaving that flexibility really and flexibility for all thedifferent aspects of the work.” (Ward sister interview714.0012, lines: 652-659)

Many ward sisters described their desire todemonstrate, through their actions, what they expectedor required of the nurses on their ward. They articulatedclearly the need to set a good example, and tocommunicate effectively with all staff about how theward was performing in order to ensure that staff wereleft in no doubt about how they would be expected toapproach their work in order to deliver high standardsof patient care.

“Our nursing metrics on the ward have picked up sincewe’ve been supervisory, um, on this ward, you know,

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we’ve maintaining to stay in the green, which is what theTrust expects us to do. Things like the friends andfamily test I’ve been able to be really vocal and reallywatch what’s going on who’s getting the audits beforepatients go home. So, for example last month ward xxwon an award of being the most improved... because Iwas able to control who was getting those audits andcontrolled getting those audits back which is reallyimportant.” (Ward sister interview 714.0028, lines: 157-168)

“...my standards of nursing are that I always like thepatient to be cared for as if they were my own relative...So yeah, it’s just about being able to talk to them andgive them that time and giving them the update. Andthat’s what I like my nursing staff to do, is one to makesure that the patients are cared for and that also aboutmaking sure the protocols are followed, that if a patientneeds to hourly turn, or they’ve got that two hourlyturning, or learning to re-assess that patient if they needit more frequently, then you do it more frequently, andjust because the protocol tells us two hours, you can doit every hour... and that they take the time to speak tothe patients and speak to the relatives... or if theyhaven’t then point them in the right direction and yeah.”(Ward sister interview 713.0006, lines: 437-460)

Ward sisters felt that the move to supervisory hadhelped them to be more effective in terms ofcommunicating their expectations in terms ofstandards. They reported they were better able to deploythemselves with new starters, newly qualified staff andstudents and were able to ensure that everyone wasmade aware of how the ward sister wanted things done.Establishing and maintaining high standards of care atward level was facilitated when ward sisters felt theywere able to work as clinician, leader and manager toexplain and clarify their expectations around thestandards of care they expected ward staff to deliver andmaintain.

“So I’m the senior person on the unit, so I’m the leaderthat they look towards, so I have to be a positive rolemodel for them in every way, so professionally, clinically,um, you know, anything really that’s visible. I need to beprofessional in every way, so that they will, hopefully,then look at me and realise that that is the way that youneed to be in a clinical environment.” (Ward sisterinterview 713.0018, lines: 780-787)

When discussing how ward sisters communicate theirexpectations to their staff some noted that once this hadbeen achieved it became implicit and so simply thepresence of the ward sister served as a prompt.

“I think it’s your persona, I think it’s the way you carryyourself, it’s about being visible and it’s about, it’s aboutyour persona.” (Ward sister interview 713.0018, lines:1571-573)

“Well I’m very much well let’s go away and talk aboutthings and you know, what’s right about this, what’swrong and then kind of try and fix it from that really... Idon’t tend to have a lot of big performance as such onthe ward, which is good and that’s how it should bebut... I’m trying to think of an example but I can onlythink of the fluid balance charts really... or it might be...if I see something I’d action it there and then and takethe person away and have a chat with them you know...”(Ward sister interview 714.0012, lines: 501-505)

“Well I’ve got a look that the girls have told me that I’vegot, um, so sometimes perhaps if I’m just walkingaround the bay I’ll just look at them and go, ‘Really?’They’ll go ‘No sister I’m sorting it now’.” (Ward sisterinterview 713.0006, lines: 596-599)

Analysis of the data from the second interviewsreflected more emphasis on the quality improvementcycle.

“You are in a position more to think about how to stopthat happening, you know, let’s look, can we changepractice, what are we doing wrong with that.” (Wardsister interview 714.0031, lines: 115-118)

Reversing negative perceptions of the wardsister role

Ward sisters recognised the potential for the positivechanges they associated with the supervisory wardsister role to reverse the negative perceptions of nursesand the public about ward sisters. They particularlyspoke about professional standards and also saw thesupervisory role as having the potential to inspire juniornurses to become a ward sister. Many talked about howmany junior nurses previously viewed a ward sister roleas one that was pressured and stressful, which in turnled them not to seek a ward sister role, but instead toseek posts as specialist or advanced practitioners, orremain as a band 6 ward nurse. There was a senseamong some of the ward sisters that since the change tothe supervisory role some of the nursing staff appearedto think more positively about taking on a ward sisterrole.

“... I think really in the past band 6s have tended to workas very good band 5s. Um, I think having thesupervisory role will enable them to be very good band6s and to be able to run a ward.” (Ward sister interview713.0014, lines: 1479-1483)

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“Yes I think so because I’ve always been, um,encouraging them that, you know, if ever there’s another,you know, a job opportunity and they were, they’re, youknow, quite eager... And they are keen to – ‘cause if Ithink when I was looking back when I was a band 6 Inever wanted to be a band 7, cause I know about thestress and the pressure but now I think that haschanged.” (Ward sister interview 713.0018, lines: 508-518)

Some ward sisters also felt there was a need to clarifywhat the supervisory role itself entailed, as theyperceived others assumed it meant not having anythingparticular to do.

“...sometimes in the back of your mind – I don’t knowmaybe I’m just being paranoid maybe they’re thinkingoh, you know, the ward sister might be supervisorymaybe... she’s free to do this, she’s free to do that, she’snot doing anything because she’s just supervisory, she’sjust standing there supervising and delegating thingsand telling people to do this and that, but, you know,that could just be me..., as I said that could just be myparanoia thinking that that’s how they might bethinking...” (Ward sister interview 713.0018, lines: 584-595)

Knowing self

In reflecting on their experiences many ward sistersarticulated a need for self-reflection, a sense of knowingthemselves and understanding and developing theirleadership style. Many participants reiterated theirpassion for nursing and a fundamental belief that beinga ward sister was the best job in the world. While being award sister brought with it many challenges participantsexpressed how being a nurse brought them a great dealof personal satisfaction. However, some also talkedabout how their sense of satisfaction and motivationhad been severely tested in the past, how they had feltbombarded, drowning and overloaded and how at theirlowest point, they had felt de-moralised, stressed, at riskof burnout with some being close to leaving nursingaltogether.

“Well I do feel more in control and less stressed becauseI did feel less in control and frustrated that I hadn’t gotthe time to do what I wanted to do. And I, I felt thatsometimes you might as well pay me as a band 5 I don’tfeel like I was doing anything like managerial youknow.” (Ward sister interview 714.0012, lines: 325-329)

Because ward sisters were at different points in theircareer trajectory they were also at different points intheir own development. Whilst reflecting on their

approach to the role, many talked of ward sisters theyhad worked for in the past, commenting on how theyhad either drawn on the positive attributes of these rolemodels or how they had vowed never to mirror thenegative elements they had experienced. Manyparticipants highlighted the importance of being a goodrole model and saw the flexibility of the supervisory roleenabling their professional approach to be more clearlyseen and appreciated by staff.

“I’ve always, since being a nurse, I’ve always, no matterwhat role I’ve been in throughout my nursing career Ilead by example. I don’t ask anybody else to do what Iwouldn’t do myself and I think, um, being in asupervisory role it allows you to do things like that. Itallows you to think there’s a buzzer going there, I haven’tgot my own group of patients to look after, and they’restruggling so I’m going to get a commode for a patient.”(Ward sister interview 714.0028, lines: 568-576)

Not being one of the gang

Some sisters recalled how they had recognised at somepoint in their career as a ward sister, that while it wasimportant to maintain a connection with the wardteam, it was also important to stand slightly apart fromthe team in order to preserve their authority as wardmanager. There seemed to be general agreement that agood ward sister remains close but distant and itappeared from some of their accounts that working inthe numbers made this difficult because the ward sisterwas seen to be doing the same things as everyone else.

The ward sisters saw the relationship betweenthemselves and their staff as crucial to leading the wardeffectively.

“...and trying to find the balance between being a goodmanager and being a friend almost, trying to find thatbalance.” (Ward sister interview 713.0014, lines: 297-199)

“...I still have a laugh with them... when the situationcalls for it, but, yeah, you know like I’ve said... they knownow the boundaries really.” (Ward sister interview714.0018, lines: 547-549)

In the early stages of the move to supervisory status itappears that ward staff continued to see the ward sisteras one of the gang, an extra pair of hands. In addition,ward sisters talked of how they felt guilty and judged byward staff when they were not seen as being clinical.This manifested itself particularly when the ward wasshort staffed or really busy and the staff expected theward sister to muck in and take a fair share of the workas just another pair of hands.

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“Because I felt really guilty when I was in the officebefore like I should be out helping them...” (Ward sisterinterview: 713.0012, lines: 567-568)

“They think I’m an extra pair of hands so that’s probablyone of the most difficult things to overcome...” (Wardsister interview 713.0014, lines: 46-48)

Alternatively however, the need to be separate from thegang was also acknowledged.

“I miss being part of the team... as a ward manager ...Iwas far more interactive with the team because I wasdoing the same as them day in, day out. But I was fallingbehind with lots of the management stuff which didn’tgive me job satisfaction... and that would really stressme out so... But I guess I do miss that bit of banterbecause I guess the boundaries are a little bit moredivided with the team because... But I guess that mightbe about my own professional development and the factthat I’ve now learned that it’s not good to have too closerelationships with your band 5s because thoseboundaries from manager to work colleagues need to behad... to be able to gain their respect and to be able to,well for them to be able to gain the understanding that ifI’m saying that I want something done it’s not a case ofoh, that’s just [xxxx] asking for that and that’ll be alrightto do it the next day it’s actually ‘Okay Sister we’ll getthat done’. And that’s far more professional for thepatients and the relatives. So I guess that part I do miss,but I am going home far less stressed”. (Ward sisterinterview 714.0014, lines: 498-525)

This view was shared by a number of the ward sistersinitially, and while they reported a willingness to roll uptheir sleeves and muck in, some made the distinctionthat this did not constitute them being seen as part ofthe numbers. As a result of these conflicting concernssome ward sisters experienced difficulties in trying towork differently both during and after the change.However, others appeared to have shifted their thinkingaround this issue over time, and subsequently felt thatpart of their role was to escalate issues up themanagement chain rather than constantly trying to fillthe staffing gap by putting themselves back in thenumbers as a temporary fix. Supervisory ward sistersalso noted that staff had begun to appreciate thebreadth of the role more clearly since the change.

“...I’m quite happy to go and get my hands dirty but...I’m nobody’s fool, they will think, oh, she hasn’t been outand made a bed today, or she hasn’t, you know, put apatient on the commode. But I don’t have to explain, Idon’t feel the need to have to explain myself to thembecause they’re not sorting out... this, that and the

other” (Ward sister interview 714.0011, lines: 807-813)

“I think how they see me as well as a leader and amanager has changed. Because before there was thatexpectation that I’d step in and be clinical no matterwhat. And they didn’t have that respect of what Iactually had to get done, so there wasn’t... that was kindof, well you should be clinical so many days and youshould only be this. And you know, very observantabout what I was doing and not realising actuallysometimes things change. Whereas now I find they needme less. It’s really... you know it’s because I’m availableand now they’ve got an understanding of what I do andwhat my role’s about, they actually are better as a team,if that makes sense.” (Ward sister interview 713.0020,lines: 230-239)

Some ward sisters recounted a realisation that they mayhave been too ready to see themselves as the only onewho could solve problems before, or that they hadpreviously taken a mothering approach to the wardsister role.

“...I’ve just done the leading at the front line course anda lot of that was, as I’ve said before, I’m a bit of a controlfreak and I always feel that I have to fix people’sproblems... I’m the one that’s gotta fix it. And what I’mtrying to do now is when people come in and say ohsuch and such, and such and such I’m gonna kind ofgive it back to them and say okay so what are you gonnado about that. So opposed to in the past where Iwould’ve gone oh let’s do this and this... And now I kindof think it’s like mothering... It’s quite hard for me to doI must admit because I’m very much I’ll fix it, I’ll do it,I’ll make you happy... So I have kind of given it back tothem and it is actually working quite well I must admit.You know, people are sorting out their issues forthemselves instead of opposed to just coming anddumping it with me, and me feeling I’ve gotta fix it youknow, they’re doing it, but it’s quite hard to stop that.”(Ward sister interview 714.0012, lines: 541-562)

“Yeah, that gives you some skills and some insight intohow you can possibly deal with things, um, so I thinkyes I have and I think you have to change slightly.”(Ward sister interview 713.0013, lines: 985-987)

Flying in the role

Within the data it was clear that some supervisory wardsisters reported a sense of greater freedom and thechance to spread their wings and fly.

“...we are being allowed to run our wards the way thatwe need to run them with the teams that we’ve got.Because as you would manage one ward you wouldn’t

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manage another ward necessarily the same because itjust depends what the dynamics are. So I feel that seniormanagement are sort of letting us fly our wings...And Ithink that is really good because it builds my confidenceup as a manager, it allows the ward to see that I am theirmanager and I am their first port of call because in yearsgone by managers would be left out of a situation... SoI’m feeling that we’re sort of gelling more as a teambecause they’re seeing that I’m there to support thembut they also acknowledge the fact that I’msupernumerary and I do have other management thingsto do as well. Also it’s a two way respect thing that’sgoing on with me and team and I think it’s the samewhen it’s me and senior management since thesupervisory role has been left it’s a case of manage yourward, these are the targets that we want you to achieve, ifyou’re not gonna be achieving them when you’ve gotyour capacity as a supervisory ward sister then you willbe asked the question ‘Well why?’” (Ward sisterinterview 714.0014, lines: 108-132)

This freedom enabled supervisory sisters to deliver thehigh standards they felt patients had a right to expect.They felt more able to maintain and sustain the qualityof patient care delivered on their wards, and it was anopportunity many were keen to embrace. Part of thismomentum for some, lay in their perception that theintroduction of the change to supervisory statusreflected an increased profile of nursing within theorganisation and also that the value of the role wasbeing acknowledged.

The sisters’ description of feeling the sense of freedomthat had come with the move to supervisory statusappears to encapsulate what was variously described ashaving time to do, or time to think and act. Whilst therewas a sense of having been given time this was agreedto be more about having the freedom to control howthey managed their time, rather than any sense ofgaining extra time. This understanding of how time wasfreed up was also recognised by some as providing amechanism for planning ahead.

“I’ve got a band 5 nurse that was struggling with[xxxxx] issues... so because I was there supporting herand guiding her... I was able to come back in here andthink what courses can I put the girl on so... she feels abit more empowered... And that can be doneimmediately rather than thinking I must do that afterI’ve finished this shift, or tomorrow I’ll put it on my listto do and actually that list to do goes to the next day’slist to do and before you know a few months haveelapsed and that band 5 may be in the same situationagain and I’ve not actually empowered her to get better.

So it gives you more time to look at what skills arerequired... because I am now able to look at the off dutyin a lot more deeper detail now... I’m now able to plan inthe off duty more in advance... So it’s about planningahead and when you’re spending a little more timelooking at your off duty with more scrutiny that’s givingyou more time to think right that girl needs to go on anend of life course... and I’m already able to identifywhere I can sort of tighten up the numbers so I can freepeople up to go” (Ward sister interview 713.0014 ,lines:250-28)

As indicated above, many ward sisters spoke aboutbeing now able to organise their work and get home ontime, and many reported how they no longer had to takework home any more, which in turn made them feel lessstressed and less pressured. While some ward sistersobserved that they had not previously had time or spaceto think much about their own future development theydid report that they now felt able to do so.

“I used to be in at 7 o'clock every morning... and it’sexhausting because... when you’re clinical, becauseyou’re doing 7am-3pm and then I had to do my officestuff afterwards, so I wasn’t going home until 6, 7, 8o'clock at night. So I was doing clinical in the morningand then I was working over. Whereas that doesn’thappen now, I can do both. And because I’m on top andbecause I’m flexible I’m able to fit it all in... I am I’mhappy because I’ve got a great work/life balance, I’ve gota great relationship with my staff because they knowthat I’m available if they need me, they know that I’mavailable (Ward sister interview 713.0020, lines: 90-106)

“I’ve just had 10 days off it’s the first time I’ve had thatamount of time off in two years because the fear ofleaving the ward” (Ward sister interview 713.0014, lines:1490-1492)

Difficulties in moving into the role

In order for the ward sister to start working in asupervisory role, additional staff were required for thewards. The period of recruitment was variable acrossboth study sites with some areas filling their vacanciesmore quickly than others. Therefore, some sistersreported having to continue working in the numbers,whilst recruitment was ongoing in their area, and theyreported how this impacted on their ability to fullydischarge a supervisory role. This meant that individualward sisters commenced undertaking the role atdifferent times to others.

A wide range of experiences were described by theparticipants, and some of these serve to show how some

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sisters continue to struggle to adopt a supervisory role.For some ward sisters who reported difficulties inembedding themselves into a supervisory role this wasconnected to shortfalls in staffing. Where wardvacancies were filled all at one time, some ward sistersalso pointed out the extra demands on them in terms ofsupporting newly qualified nurses or orientatingrecruits from overseas. However, other ward sistersreported how they had managed to use the supervisoryapproach to accommodate the needs of these staff moreeffectively.

“We expected it but I’ve taken on a lot of new staff, um,and a lot of newly qualified staff from other trusts. So,they’ve come new to the role, but also they don’t evenknow where x-ray is and so forth, I could walk them andgive them a tour of the hospital cause I didn’t haveresponsibility to do that. I can work with them I coulddo their drugs assessments, um, I can observe them todo like, if, for catheterisations, NG tubes. Um, one ofthem is really struggling with her confidence, um, andshe knows that although now I don’t work with her, sortof, I don’t micro-manage anybody but I don’t micro sortof manage her but she knows that she can just come andsay – can I ask you just a daft question – because shedoesn’t want to ask other people, um, and that worksreally, really well. What else do I get to do, um, you, youcan just observe. I’m always free to be able to speak torelatives”. (Ward sister interview 713.0006, lines: 63-78)

Other things that were identified as having a negativeimpact on a ward sister’s ability to fully take up thesupervisory role were the demands aroundperformance management and meeting targets.

“I said earlier... I felt that it would be really good, andthat it would release me to go into the clinical area. Ithink... since I’ve seen you it’s got worse and I have lessclinical time. And I had very limited clinical time then,and I think I’m pretty much office based now purelyfor... the key performances that they have set down andwhat we need to achieve and how we need to achieve it.You know we’re sitting in the office writing reports as towhy things haven’t been done, why we haven’t achievedthings, what we’re going to do and how we’re going to doit. And you know, you either make a choice of notswitching on the computer and going out clinically, butthen you’re getting phone calls to say, oh this needs to besorted out and that needs to be sorted out, and it’s allurgent. So I think, you know, going into this I thought itwould be a really good opportunity to really be out thereand doing things. But as it’s gone and how the serviceneeds of the ward have changed, things have kind of gotmore office based and worse really in relation to that,

which is a bit of a shame, but that’s how it is.” (Wardsister interview 714.0033, lines: 9-27)

There was a sense from some participants of their staffor themselves being ‘pulled’ around to cover staffinggaps and this reported as being difficult to work around.

“But then, but then, like we’ve, well we pull off the day aswell so although I’m supposed to be supervisory andEXTRA [participant’s emphasis] to the numbers thatdoesn’t work because then I have to come into thenumbers.” (Ward sister interview 714.0025, lines: 74-79)

3.3.2.3 Key category 3: Leading the wayThis key category emerged as a result of the reportsprovided by ward sisters on the role of leadership inmoving forward in a supervisory role. The sub-categories identified under this key category include:developing, educating and supporting staff; delegating;empowering staff; ‘knowing and sensing’ and rolemodelling.

“I think I probably have to use my leadership skillsmore, the managerial not so much because I thinkthings, well when I first came the ward was in such astate you know and I had to manage that, but now thatthings are more how I want them it’s less, well people areused to doing things now so I don’t have to you know...”(Ward sister interview: 713.0025, lines: 217-221)

“Leadership to me is, um, is, um, to do with likecoaching your staff and, um, allowing your staff to growand showing them how it’s done but not doingeverything for them. So giving them the confidence andthe skills to be able to do it for themselves – that’s whatleadership is for me. Leadership is about, um, helpingpeople develop in order to be able to do – so you’re notdoing everything for them but you are leading them inthe direction on how to do it for themselves.” (Wardsister interview 713.0012a/b, lines: 949-957)

Developing, educating and supporting staffA key aspect of developing staff was achieved throughdelegating a range of tasks across members of the wardteam. In addition ward sisters talked about how beingsupervisory provided them with a range ofopportunities to educate and support their ward staff ina number of ways.

“...because... I’ve got more... time I can do some training,I can go round with the staff to check documentation tocheck the care that’s being delivered, so I go round and Ican observe... what’s going on I can speak to staff andhelp support them put some mechanisms in place togive better care.” (Ward sister interview 713.0012, lines:178-183)

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“It’s really bizarre and they’ve actually stepped up andthey’re starting to grow themselves rather than – it’s hada really positive impact on them rather than a negativeone.” (Ward sister interview 713.0012, lines: 568-573)

As has already been described ward sisters talked oftheir ability to deploy themselves flexibly and how thiswas seen as beneficial in terms of being able to workwith nursing students, new starters and establishedteam members. However, there was a sense that wardstaff did need to be reassured that this was adevelopmental opportunity rather than a performancemanagement issue.

“So even going back down to basics just showing them,you know, that I’m there and I’ll dip in and do thosethings as well and just showing them that I’m there tosupport them and just checking on them as wellobviously because it’s a two way thing because, um,they’re not, it’s not the kind of thing you can make sureyour staff are doing correctly normally but I can go inand I can just look at how they’re doing things.” (Wardsister interview 713.0004, lines: 799-806)

Working alongside staff was seen as useful in providingorientation, development and support to the ward team.Sisters expressed greater confidence in staffcompetencies and skills as well as helping to reinforcestandards and set clear expectations.

“So surely there at the Board Round.. .maybe a band 5would lead it and with that confidence of havingsomebody in case of quite difficult questions you could,you know, answer that. And it’s the same with makingdecisions on the ward, I think there’s been a lot of staffdevelopment, a lot of confidence grown with takingcharge and just to know that you’ve got that support ifyou need it, but actually you don’t always need it all thetime, you actually do develop that you can actually do ityourself without having somebody constantly checkingon you. So I think a lot on the ward now, we’ve had a lot ofstaff development I think, and a lot of junior band 5s nowwill lead the board round, they’re quite confident now todo that.” (Participant, Focus Group B, lines: 61-71)

Ward staff commented how the supervisory ward sisterwas easier to locate and they found it useful to be able tocall upon the ward sister to provide them withassistance or guidance as required.

“...in the clinical area, so if there’s something that youthink, oh they’re there, you can get to them right awayrather than them being tucked away having to do theiroffice work. They’re just more visual and you can justask them there when you need to, not think, oh I’ll get

her when I get a minute. And often they’re looking andseeing and often before you needed to go to them... It’sjust a better... just better in my opinion.” (Participant,Focus Group A, lines: 307-313)

Delegating

In reporting changes to the way they worked manysupervisory ward sisters talked about how they hadbecome better at organising the team and delegatingtasks to members of the nursing team. Delegationplayed a role in providing further opportunities for staffdevelopment, it helped spread some of the managerialwork but importantly also helped prepare some staff formoving to more senior roles. Some ward sisters alsodescribed how they capitalised on individual staffinterests and used delegation to enable them to shareand learn new skills.

“I don’t delegate stuff that I should be doing but... Ithink for their development, for their job satisfaction,for them to aspire... to progress, or to do other things Ithink you’ve got to have some form of successionplanning... you know, there’s a big jump... certainlywithin xxxx for a band 5 to a band 6 and I think oftenthere’s this perception, oh yes I’m doing it now, butactually the role’s quite a bit different, theresponsibilities are quite different so I think in terms ofshowing them how to do things, rather, it’s not aquestion of dumping some of my work on them. It’sabout slowly showing them... how to do it... so part ofthe band 6s development last year was to go on theappraisal training. They now get their appraisals doneby myself and the xxxx and they’ve got some of the band5s and the HCAs... But that’s been a learningopportunity for them, it’s feels that they’re contributing,you know, learning new skills.” (Ward sister interview714.0013, lines: 317-345)

A number of ward sisters noted that delegationprovided a valuable opportunity for staff, particularlyBand 6s, to gain a deeper understanding of the wardsister role, and in some cases aspire to becoming a wardsister in the future.

“...I might seem lazy, but I don’t do any of my audits. Idon’t do any of my audits, I don’t do the off duty, I onlypick... the only one thing that I do keep on is sickness,but other people do return to works. Yes, because myband 6s do it all, I don’t... they have it on a rolling... andI’ve split the ward into three groups, so I will take ateam, and the two band 6s take a team each, so then wesplit the PDRs and that’s it, and that’s to give them...because I like to think I’m indispensable, and I like tothink the ward’s not going to run well if I’m not there

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[but] it does. Yes it still runs. And that’s the whole thingisn’t it, we’re not indispensable, so yes it’s about givingthem the knowledge and the skills to do that whilst we’renot there.” (Participant, Focus Group A, lines: 733-734)

Some ward sisters reported finding it difficult todelegate primarily because they believed their staff weretoo busy to do any additional work and they could do itmore quickly themselves. Similarly some had struggledwith IT systems and processes. However, it appearedthat for some ward sisters, the move to supervisorystatus offered them the potential to reorganise work,while simultaneously making processes more robust.

“So they’d done them but I had to show them and thatjust proved to me that now I need to delegate thoseaudits out to the band 6s so they’ve all got two to do so ifI’m ever off sick as a short notice thing then they willknow how to input it. But it was all about getting accessto the databases, they’d done the audits, but none ofthem had a password for the database... for the KPI Ialso do that because... it doesn’t take me as long... Imean if I’ve asked the band 6 to do it, yes they’ve satwith me for that hour and I’ve shown them where I getthe information from and so they would be able to do it,but it would take them a longer time. So they are able todo it, but it’s quicker for me to do...” (Ward sisterinterview 714.0005, lines: 715-733)

Empowering staff and building teams

On reflecting on how they deployed their team anumber of ward sisters spoke of how they were seekingto engender greater independence in staff and helpingthem to become more forward thinking, They did thisby providing them with opportunities to solve problemsfor themselves and take on more responsibility.

“...So yes, so at least... because that’s what I like to do,out there, looking after patients as well. So yes they pickup a part of my managerial, so they can be in here andthey have a degree of it. Because I’m not indispensableand I shouldn’t be indispensable or make the staff feelthat I am indispensable and the ward can’t run withoutme being here. So yes, I like to make sure that... it’s likenext week I’m on annual leave, so yes, so my band 6 isgoing to be picking up my workload in here, so it’s justmaking sure that if god forbid I had an accident and Iwas off for six months the ward would still be able torun, yes. And it’s quite important, because we’re notindispensable. I like to think I am, but I’m not.” (Wardsister interview 713.0022, lines: 554-567)

Developing and supporting staff in this way enabledthem to become less dependent on the supervisory

ward sister to resolve all problems. It also provided thesupervisory ward sister with a mechanism to buildmore effective teams in which individual staff membershad the capacity to take the initiative and takeownership of their individual responsibilities andaccountabilities. Many of the ward sisters reportedbeing able to invest more time in mentoring andcoaching staff, helping them in turn, to understand theboundaries of their decision-making and their sphere ofinfluence.

“I think one of the biggest things that I personally havebeen able to do is meet with all of my staff every threemonths. And I think that’s really important. That’s not inany of our KPIs or our metrics or anything like that, butI am able to do that, every three months meet with all ofmy staff. So you know, they get that one to one time thatyou wouldn’t get otherwise. That’s one thing. (Wardsister interview 713.0020, lines: 177-183)

Many ward sisters talked about the importance ofdeveloping a good understanding of their ownpreferences, personality traits, attitudes and behaviours,and those of the people they worked with in order to beable to manage effectively. It was often stated thathaving the opportunity to attend a range of leadershipcourses had helped them to develop their leadershipskills in order to be able to build a more effective wardteam. Building a happy and cohesive team was oftencited by ward sisters as an important component oftheir role and many alluded to the link between positivestaff experience and good patient experience.

“I am so proud of my team, I really am. I’ve got such agood team, but you know, I don’t think, you know, beingclinical makes that possible. I think being supervisorymakes that possible because, you know, you can seewhat’s going on, you can work with your staff; you’ve gottime to say, are you okay, how can we develop you here,how can we support you in this situation. (Ward sisterinterview 713.0020, lines: 130–135)

“...and I’ve gone home and the ward seemed happy and Ithink you can tell when the ward is happy and whenthey’re stressed. And I think I probably go home mostdays and they’re happy”. (Ward sister interview714.0006, lines: 1113-1116)

“It’s all about the quality for me, um, I do understandabout having to have flow and I will, I’ll do my best tosupport that but I think at the end of the day I’ve got 25patients in front of me and I want to know that we aredelivering really the best care that we can and that I’vegot a stable and happy work base that are competent,that they can feel that they’re supported by me as their

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manager, that we are a team that gel well together, thatlike each other, that respect each other. Um, and that wehave excellent communications” (Ward sister interview713.0011, lines: 686-695)

Knowing and sensing

As described previously, many ward sisters talked abouthow they know and sense what is happening on theward. Having both an eye and an ear on the ward meantthe supervisory ward sister was better able to monitorstandards of care, and manage performance moreeffectively.

“Well you use your eyes, you know, if you’re out workingwith someone and you can see how they respond after10 hours to a patient that’s driving them absolutelybonkers if they’re still kind and sweet to them.” (Wardsister interview 713.0011, lines: 872-876)

Knowing and sensing appeared to be an intuitive skillwhich enabled ward sisters to accumulate knowledgefirst-hand about the ways in which staff were conversingwith patients, or handling, or not handling situations.This meant the ward sister was available to immediatelystep in, allowing them the opportunity to intervene inorder to nip things in the bud and prevent issuesescalating into formal complaints. It also meant theywere able to take someone aside quietly if they felt theyneeded to improve, or they used this knowledge toassess staff training needs and then made the necessarychanges to the e-rostering to ensure staff were able toattend the training in a timely manner.

“I think it depends on the people involved, because youobviously know you’re staff quite well as to how theyreact and sometimes you know that if you’re going tochallenge them now it probably isn’t a good time but ifyou leave it to a bit later on in the afternoon whenthey’ve calmed down it might then be a better time. Ithink it depends on the individuals and it depends onwhat the situation is”. (Ward sister interview 713.0015,lines: 604-610)

Taken alongside the activities many described in termsof developing and supporting staff some ward sisterslikened their new role to being the conductor of anorchestra or the coach of a sports team.

“...I suppose I’m more like a coaching manager, whereasI’m... they don’t see... they see me as a colleague, theyrespect my position, but they don’t see me as thisauthoritarian manager that I’m the boss and what I saygoes; they don’t see that at all. If they’re unhappy about adecision or they don’t think something works, they’revery vocal. They will come up and say, I’m not sure that

this works, but this is what I think might work. And wetry it, so they see me as somebody that they come to, tomove a service forward (Ward sister interview 713.0020,lines: 267-274)

“I don’t see myself as a referee I see myself as more of abit of a co-ordinator and nurturing the best out of mystaff that I can – putting things right when they need tobe put right, um, but that’s the best similarity I can thinkI’m kind of on the line of that pitch now and I’m lookingin and I’m seeing things where they can be tackledbetter or they need to be managed at a different angle.”(Ward sister interview 714.0028, lines: 711-718)

Role modelling

Many ward sisters talked about the importance ofleading by example and regarded themselves as a rolemodel.

“As a role model, as a voice of experience, somebodythat staff and patients and relatives should be able tocome to and get the answers that they require, and if Idon’t know them to pass them onto the relevant people.So I suppose it’s about being a leader, yes.” (Ward sisterinterview 713.0023, lines: 52-56)

“I challenge, I challenge regularly I have a very goodrelationship with both of my, um, consultants, um, and Ithink if I had a ward round where I didn’t question whatthey were doing they would probably both be a littleworried about me, um, and I think role modelling thatit’s OK to challenge is important.” (Ward sister interview713.0014, lines: 706-711)

As discussed previously many were concerned tomaintain clinical credibility and for some theopportunity to work alongside staff was enabling themto pass on skills and knowledge more effectively.

“...now doing it I do feel that I’ve got a lot of experiencea lot of knowledge, a lot of clinical experience thatactually makes me the role model and the leader that Iam.” (Ward sister interview 713.0013, lines: 1459-1462)

3.3.2.4 Key Category 4: Making connections with the organisation

In this category ward sisters observations andperceptions which emerged about the change in termsof the organisational aspects of the change are explored.

Drivers for change

Many ward sisters noted their appreciation that thischange had been supported and clearly saw the role as apositive move.

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“Well I think we’ve been lucky to have the opportunityto do it and I think we were all quite excited about, youknow, the opportunity to, um, be able to, you know, tryand improve quality and have the time to do the thingswe’re supposed to do in our job description.” (Wardsister interview 713.0008, lines: 7-11)

However in thinking about how the change tosupervisory status was launched some of the wardsisters expressed initial suspicion about what lay behindthe initiative and whether the key driver to improvequality, or manage failing performance.

“...I felt it was sold to us really around the quality ofcare... I do feel we are expected to do such a lot morethan what we were before, whether it’s just because it’sbeen formalised. Because they’ve given us nine KPIsthat they want us to achieve as part of this role.., but inthe hospital itself as a whole there’s been a... huge,massive drive around floor and capacity. So there’s anexpectation now that really that’s a huge part of yourjob, so I do get quite torn between the two; the amountof managerial stuff that’s expected of us. So even just forexample today trying to do the next four weeks off duty,I’ve been doing that all morning and I’ve only done thequalified nurses... And then on top of that you have all ofthe normal stuff, you know, the HR, sickness reviews,booking everybody in for their training, complaints,RCAs, incidents all of that jazz. Then they sort of, theywant you to be present and visible on the ward, which Iunderstand and I agree with, but I think a lot of usthought we would be more out there and less in theoffice really supporting junior staff looking at ourmetrics and, you know, having more of that touchy feelypresence with the patients”. (Ward sister interview714.0011, lines: 14-46)

Some sisters speculated about whether the intentionwas to utilise measurement as a carrot or a stick andthis was an issue raised by focus group participantswhere there was a clear delineation across viewpoints.

“We have what we call an accountability meeting, so ifany of our patients develop either a fall with harm or agrade 3 or grade 4 pressure ulcer then there’s a rootcause analysis undertaken and that root cause analysisis presented to a panel... come hell or high water, and thecase is presented by the senior sister or whoever... Andwe are looking to see if there’s anything we could do todeem it avoidable or unavoidable, both with the fall withharm or the pressure ulcer... I think having thatapproach as well it gives the sisters more ammunition togo back and go, I’ve been to that meeting, the [unclear –00:24:02] aren’t being completed, the documentation

isn’t being... it gives them that... we can be like they havea big stick that they can go back and beat their staff withat times (Participant 1, Focus Group A, line: 348-362[abridged])

“...the stick’s great” (Participant 2 Focus Group line:363)

“...the carrot’s even better” (Participant 3 Focus GroupA: line 364)

“...yes you can use a carrot to gently guide them, but weall know we don’t all have nurses that can be guided, andyou do just have nurses that just... just shouldn’t benurses... so yes, so that’s where the stick/carrot come in”(Participant 2 Focus Group A, lines: 419-422)

However, there was also a view that sometimes theywere given mixed messages about expectations.

“Yeah, that’s the message, that’s the message that theywant us to do, um, for example they want us to be, wehave to be out of the office between 8.00am and10.00am and that has to be clinical time... but then we’vekind of had a couple instances where meetings havethen been put in at 9.30am. And that’s kind of the mixedmessages there...” (Ward sister interview 714.0031, lines:32-40)

Acknowledging increased visibility of thesupervisory ward sister

There were points of commonality across ward sisters’perceptions about organisation expectations of the role.Many of the ward sisters reported how a key expectationwas that the move to supervisory status would make theward sister more visible. However, some suggested thatthe need to be visible across the organisationhighlighted how some staff failed to appreciate theimportance of the managerial and leadership functionsof the supervisory ward sister role. Some ward sistershad a sense that the managerial and leadershipfunctions were viewed by some of the ward staff asbeing less important than the clinical functions of therole. However, the majority of participants believed thechange to supervisory status had resulted in wardsisters being much more visible.

“Yeah in a nutshell I think it’s about being visible andbeing proactive.” (Ward sister interview 713.0004, lines:640-641)

For some ward sisters however, being stuck in the officewas the result of having to deal with a backlog ofadministrative and managerial tasks which they feltthey had to complete before going out on the ward.

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“...when we went supervisory there was a lot ofbackdate, there was a lot of stuff that was still sat inyour... inbox... and I’m just starting to get on top of itand the systems had just becoming in place and nowthat I’ve got those, starting to get on top of thosesystems that then maybe just a matter of justmonitoring them and rolling them over and then thatwill maybe release some time for me to go out onto theward.” (Ward sister interview 714.0004, lines: 113-122)

“I’m one hundred percent in the office at the moment. Butthat is because I’m, I’m focussing on those office basedKPIs.” (Ward sister interview 714.0004, lines: 83-85)

There was also a sense from some that that assumptionswere made by the organisation that ward sisters wouldnow have more time to attend meetings since they hadbeen made supervisory, which some argued was notalways the case.

“I don’t know if it’s a downside but obviously there’smore flexibility for meetings but there also seems to befrom... higher up that we are supervisory we have moretime for meetings... it’s a little bit dictatorial... that’s notin my mind how supervisory is. Yes it’s nice to have thetime to do that but I actually I need to plan how I wantto use my time and if that’s not gonna benefit me, mypatients, my team, then I don’t... So if it feels kind of alittle bit prescriptive... you’re supervisory therefore I’veslotted this is in for you. Well actually that’s not, that’snot supervisory (laughs)... In some respects that’s alittle bit hard. I did, or do kind of feel that we’re youknow as a group of senior sisters it’s... for example wehad performance meetings of two hours and then wehad a falls meeting afterwards which was three hours inone day when you know the reason for us beingsupervisory was to be supervisory out there seeingwhat’s going on... it’s about getting that balance.” (Wardsister interview 714.0012, lines: 114-131)

While it appeared that some supervisory sisters saw anemerging opportunity to assert themselves more, othersperceived that the focus on ward management ledothers to assume that supervisory ward sisters were ableto take on additional work.

Conversely however, some other staff felt that engagingward sisters in taking on additional work was a sign ofhow far the sister’s profile had been raised; and that itwas less about asking them to do more and more aboutapproaching them for advice or expertise. Senior nursemanagers particularly saw a value in ward sisters beinginvolved more in the organisation decision-makingprocesses because they were identified as the group bestplaced to know what was required.

When discussing the provision of formal andinformation meetings, forums and networkingopportunities many of the participants recognised howa united group of supervisory ward sisters had potentialto be a powerful voice in the organisation. Some wardsisters felt the organisation was now interested in whatthey had to say and in some cases they felt their viewswere listened to and acted on.

“...we do get answers to questions – cause quite oftenyou sit there and you think you’re the only personhaving an issue and you talk about it and actually itturns out that quite a few are so, we do, realise that we’requite a strong, um, forceful body, we can effect change”.(Ward sister interview 713.0015, lines: 646-651)

“...as a group of senior sisters we’ve kind of, the last,probably the last month, six weeks maybe a little bitlonger, we’ve kind of got together more as a team andwe’ve kind of re-launched our senior sister forum. Andthere’s various things that we’re kind of, we feel a bitmore empowered to take control over. So that, that’sgood whereas before I kind of remember saying to youthat, I felt like I wanted to lead a rebellion”. (Ward sisterinterview 714.0031, lines: 41-47)

“...actually I get excited very, um, obviously the seniorsister impact, the senior sister role, because there aresenior sisters in every area of the hospital, in terms ofthe organisation it has a global effect on theorganisation and obviously when they’re setting up theirprocesses and their checks and their challenges andwhat they’re measured against – they are, they are trust,you know. [The chief nurse] is responsible for the entirehospital, so her focus is going to be how it’s going drivethe trust forward. I’m responsible for my little corner ofthe organisation and that’s what excites me.” (Wardsister interview 7130011, lines: 709-720)

Supportive mechanisms for supervisory wardsisters

While sisters across both sites reported on the provisionof both formal and informal mechanisms that enabledthem to come together as a group, their participation inthese meetings was variable due to different perceptionsaround how useful such meetings were. For some sistersmeetings were viewed these as offering ongoing supportin terms of their growing sense of individual authorityand influence. A number remarked on enjoying theopportunity to share and compare with each other andindicated that this type of peer support had not beensomething they had had previously experienced.

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“With other band 7s and at the supervisory ward sistersmeeting that we have monthly we are more familiar witheach other now and it’s quite nice to learn from eachother and know what the experiences are on otherwards and if you are having a difficulty with somethingthen it’s nice to know how other people have solved thatproblem.” (Ward sister interview 714.0028, lines 830-836)

There were some comments around the benefits ofsisters being able to allocate time to attend meetings.

“I go to the directorate meeting on a regular basis. I amnot having to send apologies to so many meetings atdirectorate level as I was before because if they wereshort on the ward.” (Ward sister interview 714.0028,lines: 532-535)

This not only meant attendance improved but also thatmeetings were more effective in terms of not having torepeat things to those who had not been at the lastmeeting.

However, alternative views were offered which suggestedthat many ward sisters did not attend meetings, andeven though attempts had been made to make meetingsmore attractive to ward sisters, attendance had notimproved.

“I think that a lot of people just don’t go still, I mean Idon’t know if it’s because they don’t chase people, ortheir matrons don’t ask them they don’t go, but I’ve justalways gone. But we found before that, well one newBand 7 said she didn’t always go because they repeatedthings, but now they’ve changed the format of it, andthey do it now so there’s less meetings but still theattendance doesn’t seem to be better.” (Ward sisterinterview 714.0025, lines: 407-413)

“I mean I haven’t been to the last one because I wasinterviewing on that day, so I don’t know what theattendance was at that one...” (Ward sister interview714.0025, line: 415)

For others meetings were viewed in a less positive lightprimarily because some people felt they did not providethem with a platform to influence organisationpriorities.

“...we’re very reactive, we’re not proactive, [supervisory]status gives you an ability to voice or express youropinions but you know I’ve come unstuck in the pastexpressing opinions... and maybe it’s because I’ve been toso many meetings... I will be a bit of a devil’s advocateabout, but some people don’t like, or they don’t wannahear the bad things... well I’m not gonna go to a meeting

and tell them all the good things... they should take thatas read.” (Ward sister interview 714.0023, lines: 606-614)

The challenges related to staffing (in terms of uplift andupskilling) and the perceived burden associated withthe managerial function (duplication of effort,incompatible IT systems and lack of clerical/adminsupport) still remained unresolved for some sisters;leading them to question how influential they were.

“...and I sort of said, you know, that I felt that we shouldhave a clerical person that just typed things up for usthat could write the off duty out for me and, and justthose little, like photocopying – I have to do my ownphotocopying which is fine, my filing is fine but I have –I’ve got 28 members of staff on my ward – so if they alldo a bit of mandatory training and I’ve all got – I couldhave like 40 odd certificates to throw in and actually abit of admin support would mean that at a band 1 or 2they could do that and I could be out there in the clinicalarea with my patients.” (Ward sister interview 714.0027,lines: 125-136)

Inequalities in the provision of admin andclerical support for supervisory ward sisters

Some ward sisters reported the burden of workloadassociated with management processes, audits andother data inputs which they felt was not onlyexacerbated through a lack of clerical or admin support,but was aggravated as the result of having to duplicatethe same information into separate IT systems.

“But it does seem a bit ludicrous that you’re enteringyour sickness three times onto three different systems.”(Ward sister interview 713.0015, lines: 862-863)

It was unclear how allocation of administrative supportwas made, as within the same organisation some wardsisters had PA support, and others did not.

“Well some sisters have got a PA some sisters haven’t gota PA, um, some sisters use them in different ways. But Ithink you do need to have some sort of – because of thevolume of work that gets generated, bearing in mindthat if I’m fully staffed I’ve got like nearly 50 directreports”. (Ward sister interview 714.0029, lines: 812-817)

There were clear variations reported from ward sistersworking in the same organisation in terms of whetheror not administrative support was provided, and theimpact a lack of such support had on a ward sister’scapacity to get through the management tasks expected.

“Um, and then to be able to follow up on what you wantthem to achieve then something as simple as doing a,

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um, a leaver form could take me 20 minutes, which thatwould be her role. So I think a lot of it is, is paperworkthat I could be offloading onto somebody else.” (Wardsister interview 714.0029, lines: 827-832)

Sustainability and measures of quality

Many ward sisters described having ‘24/7’accountability and responsibility for the ward, withsome suggesting they felt more accountable since thechange to supervisory status. While they did notnecessarily believe they had been given additional areasof responsibility many referred to the higher profile andgreater transparency being placed on accountability,specifically in relation to their ability to manage KPIs.

“I mean looking at my own KPIs you know I’ve seen thatmy sickness levels are down, now whether that’s justbecause my sickness meetings have been done on timeand people are a bit more ooh, I’ve gotta have a sicknessmeeting. Whereas before I didn’t always have time to dothem on time so it’s been about tightening up theprocess. So you know one of the ones is to improve yoursickness by one per cent which I’ve done. My patientmetrics, my nursing metrics are well have tended toalways been fairly good but where we had kind ofstruggled a little bit with the fluid balance as I said andthat’s improved.. So there’s various aspects that I can seehas improved ...” (Ward sister interview 714.0012, lines:674-682)

Many sisters articulated their understanding of theorganisations expectations of the supervisory wardsister in relation to KPIs. They recognised thesignificant financial investment that the organisationhad made in order to support the change to supervisory,as well as the requirement to show a return on thatinvestment.

“If you wanted some of these quality markers toimprove then we couldn’t go on as we were, you know,so it was great that we got the recognition and we got theinvestment. You know, brilliant, you know and we wereall, you know, really pleased that, you know. That wasrecognised.” (Ward sister interview 713.0008, lines:1106-1111)

However, this recognition also led some sisters to beconcerned about the implications for the role if the casecould not be made satisfactorily. Many supervisoryward sisters stated they would be extremely unhappy ifsupervisory status was taken away.

“But obviously, you know, the trust is very much lookingat targets, numbers, but she wanted to get the sense ofhow we felt that we were doing, you know, in an emotive

point of view. So she was fairly supportive for itcontinuing but I suppose the Trust will only kind of theywant to see the actual figures, so you did kind of feel abit, oh, a bit deflated really and, you know, how could wepossibly go back to where we were before.” (Ward sisterinterview 714.0031, lines: 1502-1511)

“I think that people do need to know that from a band 7perspective to maintain the standards and to meet thedeadlines we do need the protected time that this Trusthas given us and I think if things change withsupervisory role I think it would – certainly it wouldmake me feel quite tense because I’m thinking how can Iattain the standards what I’ve been able to attain overthe last sort of 12 months if the hours were to change or,you know, whatever would change.” (Ward sisterinterview 714. 0028, lines: 921-933)

However, there was a sense from senior managers thatthey wanted to continue to support the supervisory role.

“It’s probably changed the way... I suppose it’s kind ofmade me feel a little bit more recognised for the job thatyou actually do and that the organisation, theorganisation have come to, well they’ve kind of investedin you and they’ve given us the opportunity to you knowmake these changes. I feel more positive, more engaged.Like I’ve said I love my job and I love working for theTrust and I love my ward but you do actually think doesanybody actually care and I suppose you do kind of feelyou know actually we’re being invested in here andthere’s a lot of, yes there’s a lot of expectations and butthere’s also a lot of belief that we actually you know dothis.” (Ward sister interview 714.0012, lines: 790-799)

Whilst many sisters appreciated that importance ofmeasurement, some expressed concerns that anyoverriding focus on measurement would miss the point.For some, the essence of good care and effective teammanagement might be less tangible and so not easilymeasured. Some sisters remarked on the dangers offocusing too closely on the process of paperwork ratherthan any close examination of the questions raised bythe data, leading some to note that measurement couldbe reduced to a tick box exercise.

“But again and I know they need to have some form ofbeing able to measure our nursing performance for ourdocumentation but it isn’t always measured the same,every single ward is completely different and has verydifferent challenges, um, and I don’t know whether that’snecessarily taken into account.” (Ward sister interview714.0029, lines: 572- 578)

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However, some sisters did talk about patient feedbackand how they felt the family and friends test scores hadimproved since the change; and suggested that perhapsthis might be the result of their increased visibility andbeing more accessible to patients.

“Because the patients generally give good feedbackanyway, and every month we get lots of cards andchocolates, if you have a look outside you can see there’squite a few cards out there, and they’re all quite recent.”(Ward sister interview 714.0025, lines: 117-120)

“When you give time to your staff then the way theydeliver their care improves, so, by me giving time tothem their standards have improved and, you know, thereports that we’re getting back from the netrecommender cards is that patients are very happy onhere... So we’re getting a lot of feedback that staff knowwhat they’re doing, that staff are happy and helpful”(Ward sister interview 713.0012, lines: 193–202)

Whilst some sisters saw accountability meetings toreview KPI data as a means for being told off, othersregarded these as an opportunity to review their dataand to illuminate the discussion around performancewith specific knowledge of contributing factors,particularly to dips.

“I think the supervisory role allows me the time to lookat individual situations better and to monitor andcontrol it, so in which case the sickness has come down.I mean unanticipated sickness where people aregenuinely ill at the last minute you can’t... well you can’taccount for those because we’re human beings butcertainly the band 2s are more aware that I’m looking atwhat’s going on and I’m analysing and I am sort ofclocking it my mind, whereas before it was kind of haveI got time to do a return to work interview andobviously a return to work interview it’s key to keepingpeople off their sickness. So I’m having time to do thatand I’m able to plan and structure sickness reviewsmuch better. So that’s just one example from the KPIs.It’s reducing sickness by one per cent.” (Ward sisterinterview 714.0014, lines: 162-177)

Some ward sisters talked about the importance ofmonitoring performance and many noted success inimproving KPI scores during the period of this study.This had also prompted some to consider aspects oftheir role and impact that could not be captured byquantitative measures but were nevertheless crucial toquality improvement.

“...whether your staff are happy and those things, andyou can’t capture the data for that and whether they feel

supported and that sort of thing, so you can’t capturethat data on a monthly basis or... because it’s verysubjective isn’t it, data, so yes the data that we’recapturing on there is just your factual data on there withyour falls, your pressure ulcers.” (Ward sister interview713.0022, lines: 82-89)

“Senior managers are... they want the factualinformation, so whether your pressure ulcers are down,whether your falls are down, whether your patients arecared for, that sort of thing, whether your mandatorytraining is high, whether your PTR’s are done on time.But as I say there is that other component of being amanager, of being a team player and being supervisory,and it is yes, so whether staff are supported, whether thestaff morale is high on the ward.” (Ward sister interview713.0022, lines: 169-177)

The following example draws both issues together.

“I find that I’ve got a lot more time; I go round and seemy patients every day and ask them how they are. I’vegot free time to help my staff; I’m up to date with all ofmy office based stuff, so all of my letters are done ontime, all of my meetings are done on time.... so we’re topin our ADT, admissions, transfers and discharge. We’retop in our patient feedback and recommender cards.Our metrics have consistently stayed above 98% thewhole time. We’ve got the highest compliance ofantibiotics, so our compliance and our ability, and that’sbecause I’m able to lead, I’m able to be on the ward, I’mable to work with my staff, I’m able to make sure they’retrained.” (Ward sister interview 713.0020, lines: 7-20)

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4.1 Core and key categories

This study identified the core category of Being pivotal from analysis of participants’ perceptions, expectations andexperiences in the supervisory ward sister role. Four key categories: Reclaiming all the role; Forging a path; Leadingthe way; and Making connections in the organisation (see Figure 4.1) also emerged. These are not mutually exclusiveor hierarchical, but should be regarded as interlacing activities.

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4

Discussion

Figure 4.1 Core categories and key categories

Core category: Being pivotal

Key category 1Reclaiming the role

Key category 2 Forging a path

Key category 3 Leading the way

• Redefining beingclinical

• Deploying selfdifferently

• Stepping in andstepping out

• Autonomy, influenceand being in control

• Enthusiasm for the role

• Drivingimprovements in care

• Reversing negativeperceptions of theward sister role

• Knowing self

• Not being one of the gang

• Flying in the role

• Difficulties movinginto the role

• Developingeducation andsupporting staff

• Delegating

• Empowering staffand building teams

• Knowing andsensing

• Role modelling

• Perceptions of thechange

• Acknowledgingvisibility of wardsisters

• Supportingmechanisms forward sisters

• Sustainability

• Measures of quality

Key category 4Making connections in the organisation

This study demonstrated that moving to supervisorystatus enabled ward sisters to be pivotal, that isundertake all aspects of their role. The transition hasallowed them to find a balance between clinical andmanagerial elements of their role and to provideimproved leadership to their teams. The role requiresskill and judgement which is based on a detailedknowledge of the ward, gathered personally andinterpreted by the supervisory ward sister. Supervisoryward sisters continually build and update a 360° view oftheir ward and are able to step in and out of activities toprovide timely guidance, correction or a professionallead as required. This activity can be almostimperceptible but provides the basis for the supervisoryward sister to provide an informed and effective linkbetween the ward area and senior levels of theorganisation.

Four key aspects appear to contribute to successfultransition to supervisory status. Firstly the ward sistersseem to have reconsidered and reclaimed all the variouselements of the ward sister role. Those making thistransition appear to redefine being clinical asencompassing more than simply caring for a patientcaseload but including working alongside staff andsharing clinical skills and knowledge. In addition, theyhave taken control of their own use of time andachieved improved balance between the clinical andmanagerial elements of their work.

The supervisory ward sisters in this study have forged apath for themselves in terms of embracing the role. Thechange has prompted them to reflect on their leadershipstyle and served to reinforce the sister’s role as ‘seniorcolleague’ rather than just another pair of hands. Manyreport an increased feeling of autonomy and being lessstressed. There is also some indication that theperceptions of others about the role are also changing.This especially in relation to Bands 5 & 6 nurses, someof whom are now more interested in the prospect ofbecoming a supervisory ward sister themselves.

This study has also shown that as they take on asupervisory role, the ward sisters have been able todefine their leadership role more clearly in terms ofdeveloping staff and being a role model and managingtheir team effectively. They provide a clear lead forprofessional standards and empower other staff.

In order for the supervisory role to function effectively,there needs to be a supportive organisational climate.This is not only through investment to support theintroduction of the role, but in the provision ofopportunities to get peer group support functioningand in the engagement with ward sisters to inform

discussions on measurement particularly around KPIs.So whilst the supervisory sisters have become morevisible as individuals on their own ward, as a group theyhave become increasingly visible and potentiallyvaluable in the organisation.

4.1.1 Being pivotalKey message: This study demonstrated that themove to supervisory status maximises the pivotalnature of the ward sister role. This brings benefitsas it facilitates full realisation of the variedelements of the role: managing the team, being aclinical role model, a source of development andleading the ward team but also representing andnegotiating the interface with senior managementand the wider organisation, and being visible forpatients and their relatives.

Modern health care environments are frequentlydescribed as complex and sometimes chaotic andnurses are seen as needing to balance and make sense of‘multiple contradictory discourses’ in order to ensureservice delivery runs smoothly (Latimer, 2014). In thisstudy, the descriptions given by the sisters gave a clearsense that the supervisory role was connected withbalancing and juggling. Being pivotal can be seen interms of being essential or key, as well as providing afinely tuned balance. The supervisory ward sister roledemanded a balancing act; not only managing the team,being a clinical role model, a source of development andleading the ward team but also representing andnegotiating the interface with senior management andthe wider organisation, and being visible for patientsand their relatives.

The Report of the Mid-Staffordshire NHS FoundationTrust Public Inquiry (Francis, 2013) identifies the wardmanager’s role as being ‘… universally recognised asabsolutely critical’ (p.1518). This is supported by thefindings of this study. In addition Francis recommendsthat improved frontline leadership could be achieved bymaking the ward sister supervisory. This perceptionalso features strongly among the participants in thisstudy. What has emerged is a clear picture from thesisters involved that they felt unable to be consistentlyeffective ‘pivots’ before changing to supervisory status.The data revealed that supervisory ward sisters feltmore able to do what they believed they shouldbe/always wanted to be doing. The data also shows thatsome of the ward sisters attribute their ability toundertake the many facets of their role more effectivelyto the move to supervisory status.

This pivotal role is complex, has many facets and requires

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a high level of skill. The supervisory ward sisters reportedgathering detailed knowledge of their area. Thisknowledge ranges across the hard environment (forexample, cleanliness), through to their staff (levels ofknowledge and skill, personal factors), the patients on theward (wellbeing, concerns, relatives concerns) andincludes an understanding of how the widerorganisational goals translate to their area (targets, KPIs).A number of insights into how this knowledge andunderstanding is compiled have emerged from the data.Firstly, working in a supervisory capacity seems to haveenabled the sisters to deploy themselves more strategicallyto gather this knowledge. It also made it more likely thatthe sister witnessed things such as staff competency orbehaviour first hand. Supervisory ward sisters talkedabout being visible and making themselves available tostaff, patients and relatives. This was an overt strategy interms of knowing what is going on and what is of concernto people. However, it is also evident from the data that theward sisters were using various senses to understand theoverall performance of the ward. Not only were theyasking, watching and listening, they were also building upimpressions, sensing a change in the tempo or mood inpatients, staff and the environment. Because of the varietyof ways the ward sisters gain this knowledge, some of thisactivity is almost imperceptible to others. This almostinvisible facet of nursing knowledge gathering has beennoted elsewhere (Allen, 2014) and is arguably anunrecognised and undervalued nursing quality.

It can be argued that this knowledge is unique to theward sister and contributes heavily to their pivotalcapabilities. This is reflected in the comments by anumber of supervisory ward sisters around ‘building upan overview’ or a ‘360° view’. It is built up over time,particularly in terms of knowing the ward staff. Also(especially for supervisory ward sisters) it is gained firsthand. This means that as the ward sister becomes moreestablished, this monitoring capability can becomeincreasingly sensitive. This finding is echoed by Bonis(2009) who defines this ‘knowing’ in nursing asinvolving “a uniquely personal type of knowledge,constructed by objective knowledge interfaced with theindividual’s awareness and subjective perspective onpersonal experience; it is a dynamic process and resultof personal reflection and transformation” (p.1330).

Once the sister had this overview, they then reportedbeing able to be more proactive and make judgementsabout when, whether and how to intervene and steerthings back on course. This finding resonates with thoseof Allen (2014) who observed that nurses, in makingsense of different pieces of knowledge created theworking knowledge that sustains everyday service

delivery. This may involve seeing a developmental needin a member of staff and working alongside them toaddress it but similarly, it might enable the supervisoryward sister, in discussions with senior managers, toilluminate measurement data through anunderstanding of the context in which a particularepisode of performance had occurred.

In short, the supervisory role enable the sisters to stepin, step out and step up.

Figure 4.2 provides a model of a fully functioningsupervisory ward sister.

4.1.2 Reclaiming all the roleKey message: supervisory status appears to haveenabled ward sisters to take a holistic view of theirrole and reflect on the components which supportthem being the ward sister as opposed to justanother nurse. This has led them to work differentlyacross all the aspects of the ward sister role andeffectively ‘reclaim’ elements they were unable toachieve successfully whilst working in the numbers.

Redefining clinical

Participants reported that to function effectively theyneed to work differently to the ‘other’ nurses on the ward(see also forging a path below). They also seem to beconcerned that they retain clinical credibility. The moveto supervisory status has highlighted the conflict thatthis can generate for ward sisters; as a leader they needto work differently but in order to retain their nursingcredibility they need to be seen to be skilled in theclinical domain. This gives some indication thatredefining what ‘clinical’ means in terms of thesupervisory ward sister role may be helpful insupporting ward sisters to appreciate how they canretain their clinical expertise whilst moving away fromthe traditional view of ‘clinical’ equating to having anallocated group of patients within the ward. It seems tohave been a struggle for some ward sisters to let go ofthe concept of having a caseload.

The effect of other nurses’ expectations of everyoneneeding to ‘muck in’ appear also to have weighed heavilyfor some in this regard. This coupled with the pressureson staffing in some wards may explain why some sistershave struggled to ‘get started’ on the supervisory role,perhaps finding it more logical or less unsettling to goback into the numbers and ‘help out’. However over timeit appears that some ward sisters have redefined whatthey consider to be ‘clinical’ for a ward sister. This wouldinclude working alongside staff or allocating oneself to aspecific patient or clinical activity for a short period.

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Figure 4.2 Model of a fully functioning supervisory ward sister

A ward is shown (bottom half of figure) and reflects the functioning of the individual supervisory ward sister.Above it, the wider organisational context is shown, with other sisters functioning in a similar way (top right)and interacting with each other. The model shows how all the supervisory sisters interact with the widerorganisation, including senior managers (top left).

Visible; accessible; knowledgeable,

ensuring standards

Visible; accessible; knowledgeable

Sharing knowledge; peer support

Knowledge; interpretation of performance data

Knowledge; interpretation of

performance data about ward

Providing supportive

environment

Visible; accessible; knowledgeable,

clear expectations

Supporting; developing;

team building

WARD

OTHER SUPERVISORY WARD SISTERS

vvvvvvvvvvvv

Clin

ical v

vvvvvvvvvv Leadership

vvvvvvvvv

vv

Management

SUPERVISORY WARD SISTER

PATIENTS AND RELATIVES

MULTIDISCIPLINARY TEAM

WARD STAFF

ORGANISATION SENIOR MANAGEMENT

tttttttt

Mon

itorin

g datavvvvGathering intelligencevvvv

vvvv

Mon

itorin


vvv

Mon

itorin


vvvv

Mon

itorin


vvv

Building understanding of issues and envirom

nent

tttt

There was a concern voiced by a few ward sisters aboutlosing clinical skills, but for others this appeared to beless of a concern. Rather, some talked about being ableto share and use their expertise more effectively.Mendes, de Cruz and Angelo (2014) note that theconcept of the clinical role of the nurse has hardly beenexplored in conceptual terms and have attempted todraw together clinical attributes of this role. Theyconclude that the clinical role is a process of complexinteraction between nurses and patients with criticalthinking, informed experience and a sense of clinicalautonomy as its antecedents. It could be argued that thedata from this study indicates that the supervisory rolebuilds upon these attributes by utilising them in a widercontext of supervising and developing nursing care aswell as continuing to be involved in some elements ofclinical activity directly.

Deploying self

It was clear from the data that the supervisory wardsisters were deploying themselves differently once inthe role. This broadly manifested itself in dividing uptime flexibly between clinically based activity, often inthe morning, and managerial activities, often officebased, in the afternoon. Once again there was a range ofexperience described by participants and it isinteresting that some who were finding it difficult toachieve this new balance variously reported beingrequired to attend meetings and activities whichrequire them to be away from the ward or to be stuckwith office based paperwork. In this latter instance itcould be that they were still dealing with the backlogmany ward sisters described as having had initially. Thebacklog appears to have been generated whilst workingin the numbers and not having sufficient time to catchup. Therefore, it is possible that more of the ward sisterswill achieve their aim of deploying themselvesdifferently over time as this is addressed.

Being free from the constraints of a specific caseload andbeing able to deploy one’s own time appear to contributeto the way in which supervisory ward sisters felt they were‘stepping back ‘ and looking at what was going on andthen ‘stepping in’ and taking action where needed. Thisseems to be a key factor in the difference between the wayward sisters were working before the move to supervisorystatus and afterward. Having a clinical caseload seemed tohave hampered the ward sisters ability to gain thisoverview as many either only saw their own corner of theward, or were only able to snatch short periods of time totake stock. The sense of being pulled away from andpulled back into the clinical work reflected in the datacontrasts sharply with the sense of the ward sister being in

control of when to decide to step back and when to step inonce adopting a supervisory approach.

Those making a successful move to supervisory statusseem to have done two things. First they appear to havemade a shift in their thinking around ways to be‘clinical’ and what ‘being clinical’ means in the context ofeffective supervisory ward sister working. Second theyseem to have taken control of their own use of time,deciding how they would structure their working dayand spend their time. So whilst some ward sisters talkabout themselves and their staff being ‘pulled’ away tofills gaps in staffing (often on different wards) or ofbeing ‘required’ to attend meetings or being unable toleave the office, by contrast supervisory sisters talk ofhow they allocate themselves to do specific things suchas working alongside a student nurse or checkingdocumentation. In particular a number talked aboutenjoying the flexibility of being able to manage theirown time.

These changes may explain why these supervisory wardsisters also described increasing feelings of autonomyand influence. Some ward sisters reported that personaldevelopment such as leadership courses had helpedthem in this regard. Spreitzer (1999) has observed that“empowered individuals do not see their work situationas ‘given’ but rather something able to be shaped by theiractions.”(p 511). The resulting feeling of not onlyfreedom, but also reduced pressure, less stress and abetter work life balance was felt to be positive by theward sisters in this study.

As this autonomy becomes more evident it isunsurprising that it has had some impact on previouspatterns of relationships with other staff. The wardsister role has been described elsewhere as practitioner-manager (Hale et al (2012)) but it has also beenproposed that this blend of hands-on nursing,professional ward leadership and organisationmanagement has given rise to a number of tensions andambiguities in the ward sister role. This has led to theoften divergent and conflicting expectations of nurses,doctors and managers about the role and function ofthe ward sister. This may explain some of the mixedfeelings experienced by some sisters around the changeto supervisory status. Similarly it could reflect thedifficulties some were still experiencing in achievingsufficient recruitment to support them coming out ofthe numbers. The way in which some ward sisters feeljudged by other staff for not ‘being clinical’ can be seento impact on the ability of some to assert theirleadership and management functions. These staffperceptions appear to have started to shift in some

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wards over the course of the study from expecting theward sister to behave as just another pair of hands and‘muck in’ to appreciating the different role of thesupervisory ward sister and understanding the benefitof them deploying themselves differently. However theremay also be a need for other groups such as matrons toredefine their relationship with the ward sister workingin a supervisory role.

4.1.3 Forging a pathKey message: an effective ward sister needs to beslightly separate from the clinical team, reflect ontheir own development as leader and therebyempower themselves to set and drive expectationsand standards. The supervisory role facilitates this.

The move to supervisory status appears to have beengenerally welcomed with enthusiasm by the majority ofward sisters and although there was some scepticismamong a few, all had thought about the potential itoffered to be more effective. It is also clear that manyhad started to think about what the role meant for themin terms of their own management and leadership style.

Finding a degree of separation

The sample included nurses who had been working atward sister level for a comparatively short time andthose who had been in such a post for many years.Participants had a variety of backgrounds andexperience. From the picture emerging from the data wecan see nurses in the process of developing individuallyin their role as a ward sister. This development willnecessarily involve working out how to function as aleader rather than one of the team, how to motivate andmanage people and how to communicate a vision andget support to deliver it. Whilst this journey from noviceto expert happens in many roles there is someindication from this work that the process of becominga fully developed ward sister can be hampered by ‘beingin the numbers’.

Developing as a leader

Many ward sisters spoke about making the transition totheir first ward sister role and a key observation madein this regard was the eventual realisation that the wardsister cannot continue to be ‘one of the gang’. In order tobe able to maintain fairness and assert authority thereneeds to be a clear delineation between the ward sisterand the ward staff (McCallum, 2012). However the wardsister still needs to be close to the team in order to knowand understand personalities and work on building aneffective team.

Some ward sisters achieved that realignment ofrelationships. Others seemed to be experiencingconflicts in terms of feeling judged by teammatesespecially when staffing was short and there was anexpectation that the ward sister would just muck in.Many ward sisters spoke about the way in which staffwere moved around to cover staffing shortfalls on otherwards and so it is perhaps not surprising that staffwould expect the ward sister to also plug gaps. Howeverit could be argued that some of the staff were thereforereceiving mixed messages about whether the ward sistershould be viewed as ‘just another pair of hands’ or wasin fact different. This is supported by the comments ofsome supervisory ward sisters that over time the staffhad come to understand what the ward sister’s role nowwas and had changed their attitude accordingly. It couldbe argued that working in the numbers serves toundermine the sister’s ability to achieve the requisitedistance and that this could undermine their potentialto lead and manage the team effectively.

Many participants described undertaking some form ofleadership development. There is a focus on leadershipwithin health care generally and both organisations didprovide leadership development opportunities for wardsisters. Some participants mentioning courses appearedto feel they had been beneficial, although reaction wasmixed in terms of whether all ward sisters had takenadvantage of the various development opportunities.Mention of these courses often arose through the wardsisters commenting on the way in which the move tosupervisory status had caused them to reflect onthemselves and their style and how they had drawn oninsights from these courses to help inform theirthinking. Changes in leadership style were mentionedby a number of ward sisters, particularly in terms ofunderstanding their role in staff development.

A picture emerged of the ward sisters moving intosupervisory roles engaging more strongly with ideasaround the need to develop and empower staff and ofthis moving up their priorities, especially as they nowfelt they had time to devote to this. It is also an aspect ofthe ward sister role which has arguably diminishedpreviously (Bradshaw, 2010) Acting as a role model andteaching and transferring skills and standards to newstaff can be seen as part of the professional socialisationaspect of the ward sister role (Lewis, 1990) and animportant element in terms of professionalism innursing generally. This supports the study findings thatthese ward sisters were clearly very involved in clinicalwork, but predominantly working alongside othernurses to support and develop them. This wasparticularly notable in terms of orientating new staff

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and working with student and junior nurses. This is animportant aspect of the supervisory ward sister role asit has been shown that staff value leaders who ‘havetheir values and beliefs on show for others to recogniseand follow’ (Stanley, 2014: p.125). So here, the wardsupervisory sister can be seen demonstrating not onlytheir skills and expertise but also establishing andcommunicating standards and expectations.

Some of the ward sisters felt that junior staff (band 5and band 6 nurses) upon seeing these changes werebeginning to revise their perceptions of the ward sisterrole which had previously been negative. This is animportant finding as the reluctance of junior nurses totake on these roles is a serious current concern and hasbeen noted elsewhere (Doherty, 2003).

4.1.4 Leading the wayKey message: Supervisory ward sisters were ableto take a clearer leadership role, becoming a moreeffective leader and role model and developing staffby being alongside them. This potential forempowering ward staff supports the supervisoryward sister in becoming the standard bearer forprofessionalism in nursing.

Leading and empowering

Building on the freedom afforded by the supervisoryrole, ward sisters reported various changes to the waythey were working with and deploying their staff. Itseems they had begun to support staff in taking on newchallenges in terms of taking up link roles or leadingclinical training sessions. Nurses look for clinicalleaders who are supportive, demonstrate empowermentand foster confidence (Stanley, 2014), and in this study,ward sisters were able to focus on these aspects, and thiselicited a very positive response in many staff.Supervisory ward sisters also reported delegating workto other staff. In the case of band 6 nurses delegationwas seen as developmental as well as a sharing of theburden on the ward sister. The potential for this toorientate the band 6 nurse to the requirements of amore senior role was cited by many as a benefit.Delegation appeared to be increasing the appreciation ofstaff for the elements of the role in its entirety, givingthem a supported taste of the role and leading sometowards aspirations of becoming a supervisory wardsister themselves. Many ward sisters felt the change tosupervisory had increased the potential to encourageward nursing staff to consider seeking a ward sister rolein the future. Many ward sisters talked about using thissort of delegation to take an opportunity to do some

clinical work whilst the Band 6 undertook a specificmanagerial task.

The ward sisters were all very clear about the need to bean effective role model. Some had reflected onprofessional leadership and ensured that clearexpectations were set. This was not only in relation toachieving targets, but was also related to behaving in aprofessional way. These findings demonstrate thesupervisory ward sisters were behaving in the waysenvisaged by the Francis Report (2013): role modelling,developing staff and setting professional standards. Thisapproach also aligns with one of the essentialcompetencies for nurse leaders in 2020, outlined byHuston (2008) namely the ability to balance authenticitywith performance expectations. Huston describes this asauthentic leadership and notes that this approachinspires followers through the leader’s principles andconviction to act. Various ward sisters used the analogiesof ‘coach’ and ‘conductor’ to describe their role in relationto their ward team. This combines the notions describedpreviously about being part of the action and the teamwhilst also having a degree of separation and taking on arole of guiding and steering. The notion of thesupervisory ward sister empowering and encouragingtheir junior staff is reflective of the approach toleadership which these ward sisters were taking.

Gathering knowledge for action

Having time to move around their environmentstrategically to observe, participate, work alongside,judge the atmosphere and so on, enabled supervisorysisters to gain the overview essential for driving upquality through setting and monitoring standards ofcare. The often imperceptible nature of this element oftheir work emerged from the accounts given in thisstudy. Through sensing what was happening they couldstep in, deal with a situation and step out again, and thiswas viewed by the sisters as helping them preventproblems and be more effective. Similar findings havebeen noted by Allen (2014) who states that “These arenot plug and play capacities but built up over time andintegrated with the surroundings” (p.137).

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4.1.5 Connecting with the organisationKey message: organisational support is needed toensure ward sisters have an organisation culturethat allows them to flourish in delivering asupervisory ward sister role. The supervisory wardsister makes the connections between the ward andthe wider organisation, and their detailedknowledge of the ward and the factors affecting itenable them to gain a deeper understanding ofcomplexity to discussions about performance.

Perceptions of the change

The introduction of supervisory status for ward sistersin the two trusts appears to have been broadly greetedwith enthusiasm and a degree of excitement by most ofthe ward sisters interviewed. However this was tingedwith some scepticism on the part of some participants.Whilst they could see the potential of the role itself,there seemed to be a wariness that there may be hiddendrawbacks or agendas. This appeared to centre aroundthe perceived pressure on measuring performancethrough selected KPIs and what might result if sufficientscores were not attained. It may also reflect a generalfeeling of mistrust in terms of the broader backgroundof continual change and staffing reductions andreorganisations in the NHS. Nonetheless, the overallimpression given by the sisters is that they were keen tomove into the new role and try to make it work.

Appreciation of professional leadership atsenior level

The sisters were appreciative of the role that theirrespective chief nurses had played in championing thesupervisory role, and in successfully gaining agreementfor it to be introduced. The sense of needing to ensurethat the role had an impact and justified the financialinvestment appears to have been very clearlycommunicated across the ward sisters. What does seemto be important for the ward sisters is that the move tosupervisory status was perceived as anacknowledgement of the important nature of their role.The importance of a supportive organisational contexthas been recognised elsewhere (Hewison, 2011) and ithas been argued that the development of authenticleadership is facilitated by an ethical and engagedorganisation climate (Bamford et al., 2012). This wouldseem to support the picture emerging from the data ofthe organisation actively recognising and taking steps tosupport ward sisters in delivering the supervisory role.

The data shows that many of the ward sisters hadpreviously wanted to work in the way now expected by

the organisation, but it was the organisation support,especially in terms of improved staffing and facilitatingpeer group meetings, which enabled many of them todischarge the supervisory role. There was a palpableenthusiasm for the supervisory role coming out of thedata. This seems to be related to the sense ofprofessional achievement the wards sisters recounted. Itmay also be enhanced by the reduction of somestressors experienced previously coupled with the senseof a supportive organisational context. The datarevealed some sisters reported both vitality and a senseof learning at work. This has been described as thrivingat work, which is further enabled by a context such asinformation sharing, a climate of trust and respect(Spreitezer, 2005).

Increasing visibility

A key expectation of the change was that ward sisterswould be more visible, and the majority of participantsfelt this had been achieved. The data show that wardsisters were also beginning to form a perception ofthemselves as a group and an entity within theorganisation. However, this appears to be an emergentperception and not one which was consistently heldacross the group. There were a range of views among thegroup as to whether they were being ‘put upon’ withmore work now they were more visible, or whether thisoffered an opportunity to assert the ward sisterperspective into the business of the organisation. It ispossible that this is reflective of the range of individuals’differing experiences and a resurgence of the originalwariness to mistrust agendas. However, it may besymptomatic of a group who were once under the radargetting used to what their new landscape offers them.This emerging sense of the importance oforganisational relationships running alongside thetherapeutic relationships in nursing has been proposedby Allen (2014).

Strengthening the peer groupOverall the participants appreciated the attempts thatthe senior nurses had made to support the ward sistersin the transition; particularly with regard to arrangingmeetings and encouraging discussion and feedback.There was some data that indicated that these meetingsand discussions with other supervisory ward sisterswere becoming increasingly relevant and helpful as thesupervisory ward sister role evolved and developed.However in the meantime there is again someindication that some sisters continue to perceive somemeetings as taking them away from their clinical areaand not always worth attending. This seems to have

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been the general perception of meetings at the outset ofthe study, so there is a slight shift being reflected interms of those who’ve attended the new meetings andfeel they are making headway with them. However, someretain a scepticism about their value and do not go.Elsewhere it has been noted that designated forums todiscuss issues of common concern, problem solve andaccess peer support have been identified by ward sistersas beneficial (Mills, 2005)

Expanding the debate onKPIs/outcome/impact measures Despite the emphasis that ward sisters perceived to havebeen placed on the importance of performance againstthe KPIs, they seemed less clear about how well or badlythe role was being evaluated against these over time. It ispossible that mechanisms for broad feedback were stillin development during the period of the study. The rangeof differing attitudes to KPIs, their usefulness and theirinterpretation, may be reflective of the general debatearound measurement in health care. However it could beargued that the data from this study reflects a developingof the ward sisters’ approach to KPIs in terms of theirrole. While some ward sisters appeared to regard datacollection primarily as a burden and data review as apunitive exercise, others demonstrated clear insights intothe nature of performance measurement and describedhow discussions of performance were used asopportunities to highlight issues that impacted onspecific scores. Amongst these views, it is apparent thatmany sisters were also reflecting on the nature ofmeasurement itself. Furthermore, observations made bya number of participants that the current (quantitative)emphasis placed on KPIs results in many areas of theirimpact on patient and organisation outcomes failing toget measured, and as such, continue to go unrecognisedand potentially undervalued.

Barriers to introduction and functioningDuring the study, barriers to successful transition orfunctioning as a supervisory ward sister were identified.These include staffing shortages, and lack ofadministrative support. Trusts were clearly providingsupport in terms of staffing backfill, however a numberof ward sisters in situations where recruitment was slowfound it hard to move into supervisory working. It isclear from this study that enabling the sister to work ina supervisory way full time and not carry an allocatedpatient caseload was a key factor in supporting thesisters to embrace the full potential of the supervisoryrole effectively.

Both trusts had introduced meetings between thesisters and the chief nurse, and also facilitated peergroup meetings. These were still in development duringthis study making it difficult to comment on theirimpact. However, ward sisters found aspects of themuseful and it is possible that this will increase over time.Peer group support did seem to be something that wardsisters found useful and was made more possiblethrough being able to schedule attendance.

The provision of administrative support wasinconsistent. Some sisters reported struggling withremoving themselves from the numbers and withdealing with a heavy administrative burden. This issueis difficult as it is unclear how the decisions aroundallocation of administrative support are made (and wasnot part of our study) but it was reported by manyparticipants to be a key factor in their ability to get thebalance right. The administrative burden on wardsisters is well recognised and the positive impact ofrelieving this has been demonstrated (Mazerigarb,2013). It remains a concern that even though manyward sisters reported their ongoing attempts to arguefor administrative support and further clarity around ITsystems, many also felt their concerns were not beingaddressed.

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This study evaluated the experience of changing tosupervisory status for ward sisters through anexploration of the perceptions of ward sisters, seniornurse managers and the wider clinical team in two NHStrusts in England.

5.1 Main findings

A core category of being pivotal emerged, underpinnedby four key categories:

� reclaiming all the role

� forging a path

� leading the way

� connecting with the organisation.

The study demonstrated that the move to supervisorystatus maximises the pivotal nature of the ward sisterrole. This brings benefits as it facilitates full realisationof the varied elements of the role: managing the team,being a clinical role model, a source of development andleading the ward team but also representing andnegotiating the interface with senior management andthe wider organisation, and being visible for patientsand their relatives.

This role requires skill and judgement based on adetailed knowledge of the ward, gathered andinterpreted by the supervisory ward sister. Supervisorysisters continually build and update a 360° view of theward and use it to step in and out of activities to providetimely guidance or act as a professional lead asrequired. This almost imperceptible activity providesthe basis for the supervisory sister to step up andprovide an informed and effective link between wardarea and senior levels of the organisation.

Supervisory status appears to have enabled ward sistersto take a holistic view of their role and reflect on thecomponents which support them being the ward sisteras opposed to just another pair of hands. This has ledthem to work differently across all the aspects of theward sister role and effectively ‘reclaim’ elements theywere unable to achieve successfully whilst working inthe numbers.

It appears that supervisory ward sisters shifted theirthinking around what constitutes ‘being clinical’. Thiswas seen by these sisters as encompassing more thansimply caring for a patient caseload to include workingalongside staff and sharing clinical skills and knowledge.

Supervisory ward sisters took control of their own useof time, reporting an improved balance between clinicaland managerial elements of their work.

An effective ward sister needs to be slightly separatefrom the clinical team, reflect on their own developmentas leader and thereby empower themselves to set anddrive expectations and standard. The supervisory rolefacilitates this. Supervisory ward sisters are more visibleas individuals on their own ward and increasinglyvisible as a group in the organisation.

Supervisory ward sisters were able to take a clearerleadership role, becoming a more effective leader androle model and developing staff by being alongsidethem. This potential for empowering ward staffsupports the supervisory ward sister in becoming thestandard bearer for professionalism in nursing. Manyreported an increased feeling of autonomy and beingless stressed. Perceptions of others about the role areshifting, especially bands 5 and 6 nurses (some are nowinterested in the prospect of supervisory sister rolethemselves), as the supervisory ward sister had giventhem a vision of their future.

Connecting with the organisation is an importantdimension of their role and supervisory ward sistersgave examples of understanding of the complexelements around frontline performance and of makingwell informed, insightful connections between the wardand the wider organisation. This detailed knowledge ofthe ward and the factors affecting performance bring anunderstanding of complexity to the discussion aboutperformance.

Organisational support is needed to provide wardsisters with the context in which they can flourish anddeliver all elements of the role effectively. Such supportincludes investment to support introduction of the rolebut also provision of opportunities to promote peergroup support.

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5

Conclusion and implications

Barriers to successful transition or functioning as asupervisory ward sister were identified. These include,staffing shortages, and lack of administrative support.Some sisters took longer than others to rethink theirrole particularly in terms of changing how they deploythemselves clinically.

5.2 Main discussion points

The move appears to have been positive for those whowere successfully able to make the transition and for theorganisations in which they work. Supervisory sistersappeared to be able to achieve an improved work/lifebalance. They seemed to be deriving particularsatisfaction in being able to ensure they drove standardsby providing professional leadership and acting as a rolemodel. Their approach to developing staff seemed to behaving a knock-on effect in terms of empowering themand improving their perceptions about the ward sisterrole as a potential career option. Some ward sistersreport improvements in some areas of the KPIsassociated with monitoring of this change within thetrusts. Over time during this study, there appears tohave been a shift in the thinking of supervisory wardsisters in terms of engaging in a very informed way withquality measurement and with quality improvementcycles within their own area. It seems that as theirprofile rises within the trusts, the ward sisters areincreasingly being perceived as a knowledgeable asset.

This study has demonstrated that the impact of thesupervisory ward sister is multifaceted andencompasses many qualitative aspects, some of whichare likely to increase over time in post. It is thereforeunlikely that all benefits of the role will be easilymeasureable and may not be clearly evidentimmediately after introduction of such posts. Thisshould be taken into account when evaluating theseroles.

Trusts were clearly providing support in terms ofstaffing backfill and facilitating peer group meetings. Itis clear from this study that enabling the ward sister towork in a supervisory way full time and removing themfrom the numbers was a key factor in supporting theward sisters to embrace the full potential of thesupervisory role effectively. However the provision ofadministrative support seemed inconsistent. Thereasons for this are not clear but it continues to presentsome ward sisters with a barrier to effective working.

� Overall, the supervisory role appears to be a positivemove for ward sisters: including improved work/lifebalance; increased satisfaction around developmentof others and driving up professional standards.

� The role is having a positive effect in some cases onperceptions of others particularly on ward sister roleas a potential career option.

� Supervisory ward sisters seem to be increasinglyengaging in a very informed way with qualitymeasurement and with quality improvement cycleswithin their own area.

� As their profile rises within the trusts, thesupervisory sisters are increasingly being perceivedas a knowledgeable asset.

� All benefits of the role are unlikely to be easilymeasureable and may not be clearly evidentimmediately after introduction of such posts. Thisshould be taken into account when evaluating theseroles.

� Support in terms of staffing backfill, removing wardsisters from the numbers and facilitating peer groupmeetings provide a supportive context forsupervisory ward sisters to embrace the full potentialof the supervisory role.

� Provision of administrative support seemedinconsistent and this lack of resource is a barrier toeffective working.

5.3 Implications forpractice/research

� Organisations should ensure enabling factors such asappropriate administrative support are available tosupport the introduction of supervisory roles.

� It would be useful to examine in more detail how thedifferent aspects of the supervisory ward sister rolecan best be progressed.

� More work is needed to assess the impact of aspectsof the supervisory ward sister role that are notcurrently addressed by KPIs.

� The invisible nature of large aspects of the role suchas information gathering, synthesising, organisingand sense what is happening on the ward maycontinue to go unrecognised as a nursing quality.

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Stepping In, Stepping Out, Stepping Up · Stepping In, Stepping Out, Stepping Up Research Evaluating the Ward Sister Supervisory Role (REWardSS) ... of the new role, facilitating